Healthcare Provider Details

I. General information

NPI: 1912979204
Provider Name (Legal Business Name): FAUSTO JOSE RODRIGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE RM 18170B
LOS ANGELES CA
90095-0010
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-5008
  • Fax:
Mailing address:
  • Phone: 310-301-8771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberC173820
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberD71393
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberC173820
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number46086
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: