Provider Demographics
NPI:1760808646
Name:RODIGUEZ, GERARDO
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:RODIGUEZ
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 1:112 SW 76TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2430
Mailing Address - Country:US
Mailing Address - Phone:786-399-8621
Mailing Address - Fax:
Practice Address - Street 1:7250 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1903
Practice Address - Country:US
Practice Address - Phone:786-399-8621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2329281332U00000X, 335G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals
No335G00000XSuppliersMedical Foods Supplier