Provider Demographics
NPI:1003829540
Name:PATAKY, RODOLFO (PA)
Entity Type:Individual
Prefix:
First Name:RODOLFO
Middle Name:
Last Name:PATAKY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12781 SW 42ND ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3437
Mailing Address - Country:US
Mailing Address - Phone:305-553-2220
Mailing Address - Fax:305-553-9753
Practice Address - Street 1:12781 SW 42ND ST
Practice Address - Street 2:SUITE G
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3437
Practice Address - Country:US
Practice Address - Phone:305-553-2220
Practice Address - Fax:305-553-9753
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100832363A00000X
FLME 35662208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291949400Medicaid
FLQ29043Medicare UPIN
FLQ29043Medicare UPIN
FLU3775ZMedicare ID - Type Unspecified