MEDICARE: DR. JORGE EDUARDO RODRIGUEZ MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	A54207	CA

General Provider Information

NPI Number	:	1588670533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORGE EDUARDO RODRIGUEZ MD

Provider Business Mailing Address
First Line	:	393 E WALNUT ST
Second Line	:	PHR GROUP PROVIDER ENROLLMENT UNIT 3RD FL
City	:	PASADENA
State	:	CA
Zip	:	91188-0001
Country	:	US
Telephone Number	:	877-608-0044
Fax Number	:	877-514-0903

Provider Business Practice Location Address
First Line	:	11631 VICTORY BLVD
Second Line	:	#101
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91606-3572
Country	:	US
Telephone Number	:	818-764-8838
Fax Number	:	818-342-2238

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	12/03/2021

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