Provider Demographics
NPI:1912129263
Name:LUCERO RODRIGUEZ MD PA
Entity Type:Organization
Organization Name:LUCERO RODRIGUEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUCERO
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-718-9800
Mailing Address - Street 1:11 N ROYAL POINCIANA
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MIAMI SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33166
Mailing Address - Country:US
Mailing Address - Phone:305-718-9800
Mailing Address - Fax:305-225-9011
Practice Address - Street 1:10305 NW 41ST ST
Practice Address - Street 2:SUITE 202/205
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2396
Practice Address - Country:US
Practice Address - Phone:305-718-9800
Practice Address - Fax:305-718-9080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME938062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9311Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER