Provider Demographics
NPI:1841031945
Name:RODRIGUEZ MARTINEZ, IDALMIS
Entity type:Individual
Prefix:
First Name:IDALMIS
Middle Name:
Last Name:RODRIGUEZ MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 FLORIDA PKWY
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-9613
Mailing Address - Country:US
Mailing Address - Phone:407-600-3257
Mailing Address - Fax:
Practice Address - Street 1:902 FLORIDA PKWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34743-9613
Practice Address - Country:US
Practice Address - Phone:407-600-3257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA95373225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist