Provider Demographics
NPI:1083791941
Name:RODRIGUEZ, EVELYN
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 SE HILLMOOR DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7539
Mailing Address - Country:US
Mailing Address - Phone:772-335-9600
Mailing Address - Fax:
Practice Address - Street 1:1700 SE HILLMOOR DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7539
Practice Address - Country:US
Practice Address - Phone:772-335-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044960207Q00000X
FLME145161207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0208233OtherL & I
911019392OtherCOMMERCIAL
WA8426819OtherCHPW
WA9392ROOtherREGENCE
WA8426819Medicaid
G8854359Medicare ID - Type Unspecified
WA9392ROOtherREGENCE