Provider Demographics
NPI:1063131605
Name:RODRIGUEZ HERRADA, OSMANY LAZARO (MD)
Entity type:Individual
Prefix:
First Name:OSMANY
Middle Name:LAZARO
Last Name:RODRIGUEZ HERRADA
Suffix:
Gender:
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:PO BOX 4189
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-4189
Mailing Address - Country:US
Mailing Address - Phone:954-363-9582
Mailing Address - Fax:954-363-9663
Practice Address - Street 1:2548 SIMPSON RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4637
Practice Address - Country:US
Practice Address - Phone:407-632-4201
Practice Address - Fax:407-632-4206
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1576208D00000X, 208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120589900Medicaid