Provider Demographics
NPI:1841304185
Name:RODRIGUEZ, CARLOS JOSE (PHD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:JOSE
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3336
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-0336
Mailing Address - Country:US
Mailing Address - Phone:719-545-5211
Mailing Address - Fax:719-545-1962
Practice Address - Street 1:1301 W 17TH STREET
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-1915
Practice Address - Country:US
Practice Address - Phone:719-545-5211
Practice Address - Fax:719-545-1962
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1004103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07109952Medicaid
CO007928Medicaid
CO007928Medicaid