Provider Demographics
NPI:1124319165
Name:RODRIGUEZ, ENRIQUE (LSA)
Entity type:Individual
Prefix:MR
First Name:ENRIQUE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 CREAKWATER TERRACE
Mailing Address - Street 2:APT. 205
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746
Mailing Address - Country:US
Mailing Address - Phone:856-203-5655
Mailing Address - Fax:
Practice Address - Street 1:765 CREAKWATER TERRACE
Practice Address - Street 2:APT. 205
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746
Practice Address - Country:US
Practice Address - Phone:856-203-5655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL246ZC0007X
IL238.000374246ZC0007X
DCSA0118246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant