Healthcare Provider Details

I. General information

NPI: 1124064183
Provider Name (Legal Business Name): BENITO B RODRIGUEZ PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14502 W MEEKER BLVD
SUN CITY WEST AZ
85375-5282
US

IV. Provider business mailing address

2100 POWELL ST STE 400
EMERYVILLE CA
94608-1826
US

V. Phone/Fax

Practice location:
  • Phone: 623-214-4000
  • Fax: 623-214-4000
Mailing address:
  • Phone: 510-350-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number232
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3813
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: