Healthcare Provider Details

I. General information

NPI: 1609879360
Provider Name (Legal Business Name): LUIS G RODAS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 N OCEAN DR
LAUDERDALE BY THE SEA FL
33308-5968
US

IV. Provider business mailing address

9 NE 20TH AVE APT # 301
DEERFIELD BEACH FL
33441-6114
US

V. Phone/Fax

Practice location:
  • Phone: 954-771-4000
  • Fax: 954-776-0670
Mailing address:
  • Phone: 954-429-1303
  • Fax: 954-337-0157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9100841
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: