Provider Demographics
NPI:1780779579
Name:RODRIGUEZ, JOSE ABRAHAM (MD)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:ABRAHAM
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ABRAHAM
Other - Middle Name:
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:702 MARTIN LUTHER KING ST
Mailing Address - Street 2:
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-9314
Mailing Address - Country:US
Mailing Address - Phone:662-741-8800
Mailing Address - Fax:662-741-2700
Practice Address - Street 1:702 MARTIN LUTHER KING ST
Practice Address - Street 2:
Practice Address - City:MOUND BAYOU
Practice Address - State:MS
Practice Address - Zip Code:38762-9314
Practice Address - Country:US
Practice Address - Phone:662-741-8800
Practice Address - Fax:662-741-2700
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19905208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09151072Medicaid