Healthcare Provider Details

I. General information

NPI: 1396045266
Provider Name (Legal Business Name): JULIO L RODRIGUEZ MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 PALM BEACH BLVD STE 100
FORT MYERS FL
33905-3217
US

IV. Provider business mailing address

4881 PALM BEACH BLVD STE 100
FORT MYERS FL
33905-3217
US

V. Phone/Fax

Practice location:
  • Phone: 239-693-9191
  • Fax: 239-693-7369
Mailing address:
  • Phone: 239-693-9191
  • Fax: 239-693-7369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME59828
License Number StateFL

VIII. Authorized Official

Name: DR. JULIO LAZARO RODRIGUEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 239-693-9191