Provider Demographics
NPI:1184836595
Name:GERARDO J RODRIGUEZ, MD, PA
Entity Type:Organization
Organization Name:GERARDO J RODRIGUEZ, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:J
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-383-1245
Mailing Address - Street 1:3801 N HIGHWAY 19A
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-2228
Mailing Address - Country:US
Mailing Address - Phone:352-383-1245
Mailing Address - Fax:353-383-4401
Practice Address - Street 1:3801 N HIGHWAY 19A
Practice Address - Street 2:SUITE 400
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2228
Practice Address - Country:US
Practice Address - Phone:352-383-1245
Practice Address - Fax:353-383-4401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0064748174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377581000Medicaid
FL377581001Medicaid
FL26730XMedicare ID - Type Unspecified
FL377581001Medicaid
FL377581000Medicaid