Provider Demographics
NPI:1649230061
Name:FERNANDEZ, RODOLFO S (MD)
Entity type:Individual
Prefix:
First Name:RODOLFO
Middle Name:S
Last Name:FERNANDEZ
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 1:1255 STATE ROAD 60 E STE 500
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4302
Mailing Address - Country:US
Mailing Address - Phone:863-676-8237
Mailing Address - Fax:863-676-8207
Practice Address - Street 1:1255 STATE ROAD 60 E STE 500
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4302
Practice Address - Country:US
Practice Address - Phone:863-676-8237
Practice Address - Fax:863-676-8207
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74306207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004170900Medicaid
FL004170900Medicaid
FLFG947ZMedicare PIN