Provider Demographics
NPI:1720181357
Name:RODRIGUEZ, VIRGINIO
Entity Type:Individual
Prefix:
First Name:VIRGINIO
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:V
Other - Middle Name:
Other - Last Name:RODRIGUEZ
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:MD PA
Mailing Address - Street 1:345 CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-3114
Mailing Address - Country:US
Mailing Address - Phone:386-677-8880
Mailing Address - Fax:386-677-9880
Practice Address - Street 1:345 CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 360
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-3114
Practice Address - Country:US
Practice Address - Phone:386-677-8880
Practice Address - Fax:386-677-9880
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME566488208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256164600Medicaid
FL256164600Medicaid