Provider Demographics
NPI:1093412777
Name:RODRIGUEZ, JESRAEL T SR
Entity Type:Individual
Prefix:MR
First Name:JESRAEL
Middle Name:T
Last Name:RODRIGUEZ
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 HARMONY LN
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-9021
Mailing Address - Country:US
Mailing Address - Phone:863-899-0768
Mailing Address - Fax:
Practice Address - Street 1:701 LAKE PORT BLVD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7674
Practice Address - Country:US
Practice Address - Phone:352-728-3366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT100742251G0304X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist