Provider Demographics
NPI:1063443612
Name:GUZMAN RODRIGUEZ, TAMARA IVELISSE (MD)
Entity Type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:IVELISSE
Last Name:GUZMAN RODRIGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4672
Mailing Address - Country:US
Mailing Address - Phone:866-234-8534
Mailing Address - Fax:
Practice Address - Street 1:130 RIDGE CENTER DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-6413
Practice Address - Country:US
Practice Address - Phone:866-234-8534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15632208D00000X
FLACN 448208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1063443612Medicaid
FLACN 448OtherLICENSE
FLACN 448OtherLICENSE
FLBG9047588OtherDEA