Healthcare Provider Details

I. General information

NPI: 1053128215
Provider Name (Legal Business Name): RONALD RODRIGUEZ SURGICAL ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 SW 40TH ST APT 217
MIAMI FL
33165-4539
US

IV. Provider business mailing address

18040 SW 107TH AVE UNIT 106
MIAMI FL
33157-5298
US

V. Phone/Fax

Practice location:
  • Phone: 786-799-0268
  • Fax:
Mailing address:
  • Phone: 786-799-0268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number24-448
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number22-448
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: