Basic Information
| Provider Information | |||||||||
| NPI: | 1437279882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | RUBEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 15942 FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945782102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108464153 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8750 MOUNTAIN BLVD BLDG 69 | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946054500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108464153 | ||||||||
| FaxNumber: | 5105688416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 03/05/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 2470A2800X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Health Information | Assistant Record Technician |
No ID Information.