Provider Demographics
NPI:1871879023
Name:RODRIGUEZ, ESTEBAN JOSE
Entity type:Individual
Prefix:
First Name:ESTEBAN
Middle Name:JOSE
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 W ROYAL LN
Mailing Address - Street 2:APT 2301
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-3314
Mailing Address - Country:US
Mailing Address - Phone:956-827-2892
Mailing Address - Fax:
Practice Address - Street 1:1101 IRA E WOODS AVE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4020
Practice Address - Country:US
Practice Address - Phone:817-601-0350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50416183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist