Basic Information
| Provider Information | |||||||||
| NPI: | 1295025765 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARMONA RODRIGUEZ | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | LUIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 731 12TH AVE NW STE 100 | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734015762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802233216 | ||||||||
| FaxNumber: | 5802234184 | ||||||||
| Practice Location | |||||||||
| Address1: | 731 12TH AVE NW STE 100 | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734015762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802233216 | ||||||||
| FaxNumber: | 5802234184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 32740 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | 63064 | NY | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | 32740 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.