Provider Demographics
NPI:1114650249
Name:RODRIGUEZ, JOSE MARIANO (MA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MARIANO
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 COLLINS AVE APT 908
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-4749
Mailing Address - Country:US
Mailing Address - Phone:786-493-8064
Mailing Address - Fax:
Practice Address - Street 1:170 W 36TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5235
Practice Address - Country:US
Practice Address - Phone:786-493-8064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA63369225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist