Provider Demographics
NPI:1255857884
Name:RODULFO, RICHARD RAFAEL (SA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:RAFAEL
Last Name:RODULFO
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15241 SW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33194-2684
Mailing Address - Country:US
Mailing Address - Phone:786-832-0008
Mailing Address - Fax:
Practice Address - Street 1:15241 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33194-2684
Practice Address - Country:US
Practice Address - Phone:786-832-0008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA17-168246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant