Provider Demographics
NPI:1962504456
Name:BOLANOS, RODRIGO A (MD)
Entity Type:Individual
Prefix:DR
First Name:RODRIGO
Middle Name:A
Last Name:BOLANOS
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 1:200 AVENUE F NE STE 9118
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4131
Mailing Address - Country:US
Mailing Address - Phone:863-292-4004
Mailing Address - Fax:863-292-4005
Practice Address - Street 1:200 AVENUE F NE STE 9118
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4131
Practice Address - Country:US
Practice Address - Phone:863-297-1777
Practice Address - Fax:863-297-1756
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300224207R00000X, 207RC0001X
NC2003-00224207RC0000X
FLME121741207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909815Medicaid
1962504456OtherMEDCOST PROVIDER #
FL013541400Medicaid
P00665200OtherRAILROAD MEDICARE PROV#
143NKOtherBC/BS NC PROVIDER #
SCN0022EOtherSOUTH CAROLINA MEDICAID
1962504456OtherMEDCOST PROVIDER #