Provider Demographics
NPI:1013181650
Name:GERARDO J RODRIGUEZ M D P A
Entity Type:Organization
Organization Name:GERARDO J RODRIGUEZ M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:STAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-383-1245
Mailing Address - Street 1:611 W DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-2602
Mailing Address - Country:US
Mailing Address - Phone:352-383-1245
Mailing Address - Fax:
Practice Address - Street 1:611 W DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-2602
Practice Address - Country:US
Practice Address - Phone:352-383-1245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00064748207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5131AMedicare PIN
FLG00056Medicare UPIN