Healthcare Provider Details

I. General information

NPI: 1932191202
Provider Name (Legal Business Name): JAIME RODRIGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 PAW PAW AVE
COLOMA MI
49038-9519
US

IV. Provider business mailing address

54581 CALIFORNIA RD
DOWAGIAC MI
49047-9237
US

V. Phone/Fax

Practice location:
  • Phone: 269-468-6430
  • Fax:
Mailing address:
  • Phone: 269-782-1690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301059475
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: