Provider Demographics
NPI:1336246685
Name:RODRIGUEZ, ROMEO (MD)
Entity Type:Individual
Prefix:MR
First Name:ROMEO
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 1:685 CARNEGIE DRIVE
Mailing Address - Street 2:SUITE #230
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3583
Mailing Address - Country:US
Mailing Address - Phone:909-890-0407
Mailing Address - Fax:909-890-0575
Practice Address - Street 1:565 NO. MT. VERNON AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-2661
Practice Address - Country:US
Practice Address - Phone:909-884-9091
Practice Address - Fax:909-383-7013
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31849207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A318490Medicaid
CACJ805ZMedicare PIN
CA00A318490Medicaid