Basic Information
| Provider Information | |||||||||
| NPI: | 1871815597 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREGORIO L. RODRIGUEZ, M.D., P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 394 | ||||||||
| Address2: | 1403 E. MARSHALL STREET | ||||||||
| City: | CHARLESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736832327 | ||||||||
| FaxNumber: | 5736832373 | ||||||||
| Practice Location | |||||||||
| Address1: | 1403 E. MARSHALL STREET | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736832327 | ||||||||
| FaxNumber: | 5736832373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2010 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | RODRIGUEZ | ||||||||
| AuthorizedOfficialFirstName: | GREGORIO | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5736836066 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 33173 | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200006500 | 05 | MO | MEDICAID |