Provider Demographics
NPI:1669449963
Name:RODRIGUEZ, RAFAEL MIGUEL
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:MIGUEL
Last Name: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 1:401 N PARSON AVE
Mailing Address - Street 2:# 105
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510
Mailing Address - Country:US
Mailing Address - Phone:813-653-2775
Mailing Address - Fax:813-653-4521
Practice Address - Street 1:401 N PARSON AVE
Practice Address - Street 2:# 105
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510
Practice Address - Country:US
Practice Address - Phone:813-653-2775
Practice Address - Fax:813-653-4521
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-06
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00436832084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL130004554OtherMEDICARE RAILROAD
FL045795700Medicaid
FL045795700Medicaid
FL03824ZMedicare PIN