Healthcare Provider Details

I. General information

NPI: 1881153757
Provider Name (Legal Business Name): JORGE EVALDO RODRIGUEZ NYLUND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8707 COMPLEX DR
SAN DIEGO CA
92123-1401
US

IV. Provider business mailing address

8707 COMPLEX DR
SAN DIEGO CA
92123-1401
US

V. Phone/Fax

Practice location:
  • Phone: 619-439-2464
  • Fax:
Mailing address:
  • Phone: 619-616-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberA201148
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number69418
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: