Provider Demographics
NPI:1336400423
Name:PHYSICIAN WOUND ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PHYSICIAN WOUND ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RODZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-934-8193
Mailing Address - Street 1:9275 SW 152ND ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1701
Mailing Address - Country:US
Mailing Address - Phone:305-238-7873
Mailing Address - Fax:305-253-2586
Practice Address - Street 1:9275 SW 152ND ST
Practice Address - Street 2:SUITE 208
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1701
Practice Address - Country:US
Practice Address - Phone:305-238-7873
Practice Address - Fax:305-253-2586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGK132AMedicare Oscar/Certification