Provider Demographics
NPI:1417397894
Name:RODRIGUEZ, RAFAEL MOISES (MD)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:MOISES
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 1:4102 N MACDILL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6717
Mailing Address - Country:US
Mailing Address - Phone:813-363-7721
Mailing Address - Fax:
Practice Address - Street 1:401 N PARSONS AVE STE 105
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510
Practice Address - Country:US
Practice Address - Phone:813-653-2775
Practice Address - Fax:813-653-2775
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP2-00493542084N0400X
FL1331702084N0400X
FLME1331702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021849400Medicaid