Healthcare Provider Details

I. General information

NPI: 1538164157
Provider Name (Legal Business Name): CARLOS R RODRIGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 08/04/2023
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14100 58TH ST N
CLEARWATER FL
33760-9900
US

IV. Provider business mailing address

14100 58TH ST N
CLEARWATER FL
33760-9900
US

V. Phone/Fax

Practice location:
  • Phone: 727-824-8181
  • Fax: 727-824-8150
Mailing address:
  • Phone: 727-824-8181
  • Fax: 727-824-8150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME82799
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME82799
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: