Healthcare Provider Details

I. General information

NPI: 1245259647
Provider Name (Legal Business Name): RUSSELL GERALD RODRIGUEZ M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 LONE TREE WAY
ANTIOCH CA
94509-6200
US

IV. Provider business mailing address

2100 POWELL ST STE 920
EMERYVILLE CA
94608-1826
US

V. Phone/Fax

Practice location:
  • Phone: 925-779-7273
  • Fax:
Mailing address:
  • Phone: 510-350-2600
  • Fax: 510-879-9100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA84370
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA84370
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: