Provider Demographics
NPI:1285735654
Name:RODRIGUEZ TRAVIS, MARIA THERESA (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:THERESA
Last Name:RODRIGUEZ TRAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:TRAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5 LORIAN CIR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-2662
Mailing Address - Country:US
Mailing Address - Phone:501-912-3953
Mailing Address - Fax:
Practice Address - Street 1:5 LORIAN CIR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-2662
Practice Address - Country:US
Practice Address - Phone:501-912-3953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6465207Q00000X
ARC-6465208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR115541001Medicaid
ARC67755Medicare UPIN
AR50176Medicare PIN