Provider Demographics
NPI:1104047489
Name:RODRIGUEZ, PEDRO E
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:E
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4629 NW 199TH ST
Mailing Address - Street 2:
Mailing Address - City:CAROL CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33055-1508
Mailing Address - Country:US
Mailing Address - Phone:305-625-9411
Mailing Address - Fax:305-625-9410
Practice Address - Street 1:4629 NW 199TH ST
Practice Address - Street 2:
Practice Address - City:CAROL CITY
Practice Address - State:FL
Practice Address - Zip Code:33055-1508
Practice Address - Country:US
Practice Address - Phone:305-625-9411
Practice Address - Fax:305-625-9410
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00127811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL073592200Medicaid