Healthcare Provider Details

I. General information

NPI: 1588347942
Provider Name (Legal Business Name): RODOLFO BERMUDEZ MARTELL SA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 08/21/2026
Certification Date: 10/05/2023
Deactivation Date: 03/19/2024
Reactivation Date: 08/21/2026

III. Provider practice location address

19522 NW 79TH PL
HIALEAH FL
33015-6338
US

IV. Provider business mailing address

19522 NW 79TH PL
HIALEAH FL
33015-6338
US

V. Phone/Fax

Practice location:
  • Phone: 305-615-9368
  • Fax:
Mailing address:
  • Phone: 305-615-9368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number23-543
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: