Healthcare Provider Details

I. General information

NPI: 1568674687
Provider Name (Legal Business Name): DEBORAH RODRIGUEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

771 OLD NORCROSS RD STE 120
LAWRENCEVILLE GA
30046-4386
US

IV. Provider business mailing address

771 OLD NORCROSS RD STE 120
LAWRENCEVILLE GA
30046-4386
US

V. Phone/Fax

Practice location:
  • Phone: 770-670-6920
  • Fax: 770-670-6927
Mailing address:
  • Phone: 770-670-6920
  • Fax: 770-670-6927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number036119225
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number062599
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125-048742
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: