Healthcare Provider Details

I. General information

NPI: 1063443612
Provider Name (Legal Business Name): TAMARA IVELISSE GUZMAN RODRIGUEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 03/07/2023
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 RIDGE CENTER DR
DAVENPORT FL
33837-6413
US

IV. Provider business mailing address

47 5TH ST NW
WINTER HAVEN FL
33881-4672
US

V. Phone/Fax

Practice location:
  • Phone: 866-234-8534
  • Fax:
Mailing address:
  • Phone: 866-234-8534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15632
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN 448
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: