Healthcare Provider Details

I. General information

NPI: 1669748570
Provider Name (Legal Business Name): MR. ALEXIS PHYLLIP RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2012
Last Update Date: 11/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE CENTRAL BUILDING, ROOM 600D (R-60)
MIAMI FL
33136-1005
US

IV. Provider business mailing address

PO BOX 12493
MIAMI FL
33101-2493
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-5215
  • Fax:
Mailing address:
  • Phone: 305-585-5315
  • Fax: 305-355-2242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME128507
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: