Healthcare Provider Details

I. General information

NPI: 1629657390
Provider Name (Legal Business Name): GERARDO FAVIAN RODRIGUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4304 MESA DR
DENTON TX
76207-3434
US

IV. Provider business mailing address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

V. Phone/Fax

Practice location:
  • Phone: 940-381-1501
  • Fax: 940-591-7830
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberV2561
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: