Provider Demographics
NPI:1073598611
Name:RODRIGUEZ, WAYNE D (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:D
Last Name:RODRIGUEZ
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR STE 2G
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-549-0528
Practice Address - Fax:321-722-3843
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35594207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067516400Medicaid
FL390005081OtherRR MEDICARE
FL05456ZMedicare PIN
FL390005081OtherRR MEDICARE