Provider Demographics
NPI:1295978740
Name:RODRIGUEZ, GUSTAVO (MD)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9049
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-9049
Mailing Address - Country:US
Mailing Address - Phone:303-415-5816
Mailing Address - Fax:303-293-0625
Practice Address - Street 1:101 ERIE PKWY, STE 201C
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:CO
Practice Address - Zip Code:80516
Practice Address - Country:US
Practice Address - Phone:303-415-5816
Practice Address - Fax:303-293-0625
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ0552207Q00000X
CODR.0053640207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX426339ZTUAMedicare PIN