Healthcare Provider Details

I. General information

NPI: 1639247646
Provider Name (Legal Business Name): IRIS YOLANDA RODRIGUEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 UNION AVE
CRESCENT CITY FL
32112-4432
US

IV. Provider business mailing address

1302 RIVER ST
PALATKA FL
32177-5042
US

V. Phone/Fax

Practice location:
  • Phone: 386-698-1232
  • Fax: 386-698-4154
Mailing address:
  • Phone: 386-328-0108
  • Fax: 386-325-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14287
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN622
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: