Healthcare Provider Details

I. General information

NPI: 1265527956
Provider Name (Legal Business Name): GUSTAVO RODRIGUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE KELLOGG CANCER CENTER
EVANSTON IL
60201-1718
US

IV. Provider business mailing address

2650 RIDGE AVE KELLOGG CANCER CENTER
EVANSTON IL
60201-1718
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2639
  • Fax: 847-733-5618
Mailing address:
  • Phone: 847-570-2639
  • Fax: 847-733-5618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036075204
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number036075204
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: