Basic Information
| Provider Information | |||||||||
| NPI: | 1215388988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANCAY RODRIGUEZ | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | MARIO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7335 | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306047335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065467484 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100166402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122635506 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2016 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 90245 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.