Healthcare Provider Details

I. General information

NPI: 1326351131
Provider Name (Legal Business Name): JONATHAN MARIAN RODRIGUES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2010
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 E BROADWAY AVE
BISMARCK ND
58501-4451
US

IV. Provider business mailing address

715 E BROADWAY AVE
BISMARCK ND
58501-4451
US

V. Phone/Fax

Practice location:
  • Phone: 701-323-8922
  • Fax:
Mailing address:
  • Phone: 701-323-8922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2010018334
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number14015
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14015
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: