Healthcare Provider Details

I. General information

NPI: 1174040497
Provider Name (Legal Business Name): IDAYLI PEREZ RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 S HOMESTEAD BLVD
HOMESTEAD FL
33030-7309
US

IV. Provider business mailing address

363 S HOMESTEAD BLVD
HOMESTEAD FL
33030-7309
US

V. Phone/Fax

Practice location:
  • Phone: 305-775-9839
  • Fax:
Mailing address:
  • Phone: 305-775-9839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number019966
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1086
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number14321-I
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: