Provider Demographics
NPI:1205031853
Name:RODRIGUEZ, JUAN CARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2721 DEL PRADO BLVD S STE 200
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-5783
Mailing Address - Country:US
Mailing Address - Phone:239-673-9034
Mailing Address - Fax:239-673-9102
Practice Address - Street 1:2721 DEL PRADO BLVD S STE 200
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-5783
Practice Address - Country:US
Practice Address - Phone:239-673-9034
Practice Address - Fax:239-673-9102
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME604102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023711500Medicaid