Provider Demographics
NPI:1306906300
Name:RODRIGUEZ, VICTOR JESUS JR (RD)
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:JESUS
Last Name:RODRIGUEZ
Suffix:JR
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 N HIGHWAY A1A APT 2-202
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-2286
Mailing Address - Country:US
Mailing Address - Phone:321-773-0996
Mailing Address - Fax:
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3278
Practice Address - Country:US
Practice Address - Phone:321-434-7000
Practice Address - Fax:321-434-8719
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND3932133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered