Basic Information
| Provider Information | |||||||||
| NPI: | 1912979204 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | FAUSTO | ||||||||
| MiddleName: | JOSE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018771 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10833 LE CONTE AVE RM 18170B | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900950010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102065008 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | D71393 | MD | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0105X | C173820 | MD | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0105X | 46086 | MN | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0102X | C173820 | MD | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 540628500 | 05 | MN | MEDICAID | 038455100 | 05 | MD | MEDICAID |