Provider Demographics
NPI:1346292620
Name:RODRIGUEZ, GERARDO J (MD)
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:J
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 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:352-383-4401
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:352-383-4401
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00064748174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3775810000Medicaid
FL377581001Medicaid
FLG00056Medicare UPIN
FL26730XMedicare ID - Type UnspecifiedLEESBURG
FL377581001Medicaid