MEDICARE: STEPHANIE DIAZ-RODRIGUEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1487401550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE DIAZ-RODRIGUEZ

Provider Business Mailing Address
First Line	:	H4 CALLE DOMINGO OLIVIERI GRAU
Second Line	:
City	:	YAUCO
State	:	PR
Zip	:	00698-3120
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 FOWLER GROVE BLVD
Second Line	:
City	:	WINTER GARDEN
State	:	FL
Zip	:	34787-5597
Country	:	US
Telephone Number	:	407-656-0042
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2024
Last Update Date	:	05/05/2026

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