Healthcare Provider Details

I. General information

NPI: 1578976205
Provider Name (Legal Business Name): LIZBETH RODRIGUEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5359 W FULLERTON AVE
CHICAGO IL
60639-1450
US

IV. Provider business mailing address

5359 W FULLERTON AVE
CHICAGO IL
60639-1450
US

V. Phone/Fax

Practice location:
  • Phone: 773-836-2785
  • Fax:
Mailing address:
  • Phone: 773-836-2785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036141436
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: