Provider Demographics
NPI:1174040497
Name:PEREZ RODRIGUEZ, IDAYLI
Entity Type:Individual
Prefix:
First Name:IDAYLI
Middle Name:
Last Name:PEREZ 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 1:903 NW 97TH AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-2354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:363 S HOMESTEAD BLVD
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-7309
Practice Address - Country:US
Practice Address - Phone:855-226-6633
Practice Address - Fax:866-285-7068
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR019966208D00000X
PR14321-I390200000X
FLACN1086208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108539300Medicaid