Healthcare Provider Details

I. General information

NPI: 1982938502
Provider Name (Legal Business Name): GIBRHAM RODRIGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E ROOSEVELT ST
PHOENIX AZ
85008-4973
US

IV. Provider business mailing address

5302 E VAN BUREN ST UNIT 2052
PHOENIX AZ
85008-7972
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-5808
  • Fax:
Mailing address:
  • Phone: 602-502-0693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR70228
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number85793
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberR70228
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: