Provider Demographics
NPI:1457390056
Name:RODRIGUEZ, JOHNNY R (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:R
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1177
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-1177
Mailing Address - Country:US
Mailing Address - Phone:918-635-3100
Mailing Address - Fax:918-635-3398
Practice Address - Street 1:105 WALL ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4433
Practice Address - Country:US
Practice Address - Phone:918-635-3100
Practice Address - Fax:918-635-3398
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK3524208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKF82146Medicare UPIN