Provider Demographics
NPI:1992989131
Name:RODRIGUEZ, JORGE (OTC/CST)
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:OTC/CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12264 EL CAMINO REAL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3060
Mailing Address - Country:US
Mailing Address - Phone:858-847-0800
Mailing Address - Fax:858-724-0450
Practice Address - Street 1:12264 EL CAMINO REAL
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3060
Practice Address - Country:US
Practice Address - Phone:858-847-0800
Practice Address - Fax:858-724-0450
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA050842246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA050842OtherOTC CERTIFICATION