Provider Demographics
NPI:1568860419
Name:RODRIGUEZ, MAURICIO ENRIQUE (MD)
Entity Type:Individual
Prefix:
First Name:MAURICIO
Middle Name:ENRIQUE
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 1:5088 NW 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33166-5551
Mailing Address - Country:US
Mailing Address - Phone:786-509-8350
Mailing Address - Fax:239-561-2933
Practice Address - Street 1:5088 NW 74TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33166-5551
Practice Address - Country:US
Practice Address - Phone:786-509-8350
Practice Address - Fax:786-633-3688
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1297412084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017067100Medicaid