Provider Demographics
NPI:1851657019
Name:COUSINS, RODERICK D
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:D
Last Name:COUSINS
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 1:1613 N HARRISON PKWY
Mailing Address - Street 2:SUITE 200 MAILSTOP SLT 9A
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2896
Mailing Address - Country:US
Mailing Address - Phone:954-838-2371
Mailing Address - Fax:954-616-3866
Practice Address - Street 1:11750 SW 40TH ST.
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175
Practice Address - Country:US
Practice Address - Phone:305-921-0961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME123099207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program