Basic Information
| Provider Information | |||||||||
| NPI: | 1629056387 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 SADDLE BRONC DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799257045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155932033 | ||||||||
| FaxNumber: | 9155953916 | ||||||||
| Practice Location | |||||||||
| Address1: | 1160 SADDLE BRONC DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799257045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155932033 | ||||||||
| FaxNumber: | 9155953916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 07/15/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | H5485 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 098826301 | 05 | TX | MEDICAID |