Provider Demographics
NPI:1912979204
Name:RODRIGUEZ, FAUSTO JOSE (MD)
Entity Type:Individual
Prefix:
First Name:FAUSTO
Middle Name:JOSE
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8771
Mailing Address - Fax:
Practice Address - Street 1:10833 LE CONTE AVE RM 18170B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0010
Practice Address - Country:US
Practice Address - Phone:310-206-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD71393207ZP0105X
MDC173820207ZP0105X, 207ZP0102X
MN46086207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN540628500Medicaid
MD038455100Medicaid
H94554Medicare UPIN
MNP00055941Medicare ID - Type UnspecifiedRAILROAD
MD20687YWBMedicare PIN
MN220001318Medicare PIN
MD038455100Medicaid