Provider Demographics
NPI:1134141690
Name:RODRIGUEZ CONN, FULVIA (MD)
Entity Type:Individual
Prefix:
First Name:FULVIA
Middle Name:
Last Name:RODRIGUEZ CONN
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 1:5707 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-4350
Mailing Address - Country:US
Mailing Address - Phone:813-272-2244
Mailing Address - Fax:813-272-3766
Practice Address - Street 1:5707 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4350
Practice Address - Country:US
Practice Address - Phone:813-272-2244
Practice Address - Fax:813-272-3766
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME571612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54557OtherBLUE SHIELD OF FL
FL002729200Medicaid
FL002729200Medicaid
FL54557OtherBLUE SHIELD OF FL