Provider Demographics
NPI:1396203956
Name:RODRIGUEZ, IVAN GABRIEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:GABRIEL
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14499 N DALE MABRY HWY STE 130-S
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2078
Mailing Address - Country:US
Mailing Address - Phone:813-530-1414
Mailing Address - Fax:
Practice Address - Street 1:14499 N DALE MABRY HWY STE 130-S
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2078
Practice Address - Country:US
Practice Address - Phone:813-530-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-03
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11209103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA3858OtherBLUE CROSS BLUE SHIELD