Provider Demographics
NPI:1649292012
Name:RODRIGUEZ, IVAN DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:DAVID
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 NW 167TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-8452
Mailing Address - Country:US
Mailing Address - Phone:305-824-0706
Mailing Address - Fax:
Practice Address - Street 1:7100 W 20TH AVE
Practice Address - Street 2:SUITE 504
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1897
Practice Address - Country:US
Practice Address - Phone:305-827-3330
Practice Address - Fax:305-824-4699
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7908207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259931700Medicaid
FL259931700Medicaid
FLE3477Medicare ID - Type Unspecified