Provider Demographics
NPI:1033372073
Name:BELALCAZAR ARDILA, RODRIGO (MD,)
Entity Type:Individual
Prefix:
First Name:RODRIGO
Middle Name:
Last Name:BELALCAZAR ARDILA
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2196 SW 166TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-4444
Mailing Address - Country:US
Mailing Address - Phone:305-794-2744
Mailing Address - Fax:
Practice Address - Street 1:2196 SW 166TH AVE
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-4444
Practice Address - Country:US
Practice Address - Phone:305-794-2744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9848207W00000X, 208000000X
NY249662207W00000X, 208000000X
GA062187207W00000X, 208000000X
FLME 105283207W00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001466700Medicaid