Provider Demographics
NPI:1417311622
Name:LAVANDERA RODRIGUEZ, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:LAVANDERA RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13533 SW 62ND ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-5094
Mailing Address - Country:US
Mailing Address - Phone:716-423-3042
Mailing Address - Fax:
Practice Address - Street 1:1995 E OAKLAND PARK BLVD STE 310
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1138
Practice Address - Country:US
Practice Address - Phone:954-791-6146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15-528363AS0400X
FL11012299363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical