Provider Demographics
NPI:1104818525
Name:RODRIGUEZ, CHARLES L (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
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 1:329 NOKOMIS AVE S STE K&M
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-2418
Mailing Address - Country:US
Mailing Address - Phone:941-800-4305
Mailing Address - Fax:941-800-4963
Practice Address - Street 1:329 NOKOMIS AVE S
Practice Address - Street 2:STE M
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2418
Practice Address - Country:US
Practice Address - Phone:941-800-4305
Practice Address - Fax:941-800-4963
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88067208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267751200Medicaid
FL71905OtherBCBS
FL71905YOtherPTAN
FLP00072142OtherMEDICARE RR
FLH91879Medicare UPIN
FL71905ZMedicare PIN