Healthcare Provider Details

I. General information

NPI: 1629779889
Provider Name (Legal Business Name): JUAN CARLOS RODRIGUEZ RNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 PONCE DE LEON BLVD
CORAL GABLES FL
33134-2049
US

IV. Provider business mailing address

1890 RED RD STE 103
MIAMI FL
33155-2164
US

V. Phone/Fax

Practice location:
  • Phone: 855-500-3467
  • Fax: 888-203-5035
Mailing address:
  • Phone: 855-500-3567
  • Fax: 888-203-5035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11025184
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: