Healthcare Provider Details

I. General information

NPI: 1013059385
Provider Name (Legal Business Name): JAVIER RODRIGUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 FAIRMOUNT AVE PEDIATRICS DEPARTMENT
SAN DIEGO CA
92105-1608
US

IV. Provider business mailing address

4060 FAIRMOUNT AVE
SAN DIEGO CA
92105-1608
US

V. Phone/Fax

Practice location:
  • Phone: 619-255-9154
  • Fax: 619-795-9847
Mailing address:
  • Phone: 619-280-4213
  • Fax: 619-280-3545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA82639
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: