Healthcare Provider Details

I. General information

NPI: 1184623886
Provider Name (Legal Business Name): JACK JOSEPH RODRIGUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: NATCHEZ ONCOLOGY CLINIC INCORPORATED

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 02/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 JEFFERSON DAVIS BLVD SUITE 120
NATCHEZ MS
39120-5104
US

IV. Provider business mailing address

400 S COMMERCE ST
NATCHEZ MS
39120-3506
US

V. Phone/Fax

Practice location:
  • Phone: 601-442-9210
  • Fax: 601-442-7409
Mailing address:
  • Phone: 601-442-9210
  • Fax: 601-442-7409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number15252
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: