Provider Demographics
NPI:1811046485
Name:RODRIGUEZ, CARLOS GUSTAVO (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:GUSTAVO
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 1:1403 N FAIR OAKS AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1858
Mailing Address - Country:US
Mailing Address - Phone:626-398-0354
Mailing Address - Fax:
Practice Address - Street 1:1403 N FAIR OAKS AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1858
Practice Address - Country:US
Practice Address - Phone:626-398-0354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A565020OtherBLUE CROSS BLUE SHIELD
CA00A565020Medicaid
CAGR0100500Medicaid
CA00A565020Medicaid
CAGR0100500Medicaid
CA00A565020OtherBLUE CROSS BLUE SHIELD