Provider Demographics
NPI:1124087515
Name:RODRIGUEZ, DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 UTAH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-4817
Mailing Address - Country:US
Mailing Address - Phone:424-290-8004
Mailing Address - Fax:813-254-4597
Practice Address - Street 1:2330 UTAH AVE STE 200
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4817
Practice Address - Country:US
Practice Address - Phone:424-290-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME697212085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL118702Medicaid
FL253690100Medicaid
FL300097983Medicare PIN
FL253690100Medicaid
FL300097984Medicare PIN
FL300098175Medicare PIN
FL42731PMedicare PIN
FL42731QMedicare PIN
FL42731Medicare PIN
FL300125435Medicare PIN
AL118702Medicaid