Provider Demographics
NPI:1699113993
Name:SERGIO DE JESUS RODRIGUEZ, MD PA
Entity type:Organization
Organization Name:SERGIO DE JESUS RODRIGUEZ, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:DE JESUS
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-749-3677
Mailing Address - Street 1:2020 NE 163RD ST
Mailing Address - Street 2:SUITE # 108
Mailing Address - City:N MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-4927
Mailing Address - Country:US
Mailing Address - Phone:305-749-3677
Mailing Address - Fax:305-749-3685
Practice Address - Street 1:2020 NE 163RD ST
Practice Address - Street 2:SUITE # 108
Practice Address - City:N MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-4927
Practice Address - Country:US
Practice Address - Phone:305-749-3677
Practice Address - Fax:305-749-3685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty