Provider Demographics
NPI:1881153757
Name:RODRIGUEZ NYLUND, JORGE EVALDO
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:EVALDO
Last Name:RODRIGUEZ NYLUND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-3970
Mailing Address - Country:US
Mailing Address - Phone:520-270-6515
Mailing Address - Fax:
Practice Address - Street 1:500 W THOMAS RD STE 900A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4223
Practice Address - Country:US
Practice Address - Phone:602-406-3540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ69418207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program