Provider Demographics
NPI:1457573164
Name:RODRIGUEZ, CARLOS G (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:G
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 1:9626 E 147TH PL
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80602-5758
Mailing Address - Country:US
Mailing Address - Phone:303-875-6072
Mailing Address - Fax:
Practice Address - Street 1:965 PLATTE RIVER BLVD UNIT O
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-4353
Practice Address - Country:US
Practice Address - Phone:303-655-9866
Practice Address - Fax:303-655-9869
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36368207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54634369Medicaid
COROC64734OtherBLUE CROSS BLUE SHIELD
COH07808Medicare UPIN
COROC64734OtherBLUE CROSS BLUE SHIELD