Healthcare Provider Details

I. General information

NPI: 1508829185
Provider Name (Legal Business Name): JOSE ANTONIO RODRIGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7965 SIERRA AVE STE E
FONTANA CA
92336-3329
US

IV. Provider business mailing address

742 W HIGHLAND AVE
SAN BERNARDINO CA
92405-3839
US

V. Phone/Fax

Practice location:
  • Phone: 909-356-4459
  • Fax: 909-355-4261
Mailing address:
  • Phone: 909-376-4438
  • Fax: 909-881-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA78410
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: