Basic Information
| Provider Information | |||||||||
| NPI: | 1770504573 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | JAIME | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 DAIRY STREET | ||||||||
| Address2: | |||||||||
| City: | MIDLAND PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2012897258 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30 PROSPECT AVENUE | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5519961548 | ||||||||
| FaxNumber: | 5519963298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 07/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 25MA06030500 | NJ | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 7427000 | 05 | NJ | MEDICAID |