Provider Demographics
NPI:1649977141
Name:RODRIGUEZ, JORGE DAVID (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:DAVID
Last Name:RODRIGUEZ
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 1:1467 FOX SQUIRREL DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-9547
Mailing Address - Country:US
Mailing Address - Phone:863-326-8128
Mailing Address - Fax:
Practice Address - Street 1:1467 FOX SQUIRREL DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-9547
Practice Address - Country:US
Practice Address - Phone:863-326-8128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation