Healthcare Provider Details

I. General information

NPI: 1821035429
Provider Name (Legal Business Name): JORGE O RODRIGUEZ DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 ATLANTA RD SE STE 107
SMYRNA GA
30080-6431
US

IV. Provider business mailing address

4441 ATLANTA RD SE STE 107
SMYRNA GA
30080-6431
US

V. Phone/Fax

Practice location:
  • Phone: 470-956-0330
  • Fax: 678-842-5525
Mailing address:
  • Phone: 470-956-0330
  • Fax: 678-842-5525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0096-01707
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-5890
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0096-01707
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberE-5890
License Number StateAR
# 5
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number63947
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: