Provider Demographics
NPI:1396045266
Name:JULIO L RODRIGUEZ MD PA
Entity Type:Organization
Organization Name:JULIO L RODRIGUEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIO
Authorized Official - Middle Name:LAZARO
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-693-9191
Mailing Address - Street 1:4881 PALM BEACH BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-3217
Mailing Address - Country:US
Mailing Address - Phone:239-693-9191
Mailing Address - Fax:239-693-7369
Practice Address - Street 1:4881 PALM BEACH BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-3217
Practice Address - Country:US
Practice Address - Phone:239-693-9191
Practice Address - Fax:239-693-7369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052174400Medicaid
FL11909BMedicare PIN