Healthcare Provider Details

I. General information

NPI: 1265869705
Provider Name (Legal Business Name): VIRGINIO RODRIGUEZ III
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 CLYDE MORRIS BLVD STE 360
ORMOND BEACH FL
32174-3114
US

IV. Provider business mailing address

345 CLYDE MORRIS BLVD STE 360
ORMOND BEACH FL
32174-3114
US

V. Phone/Fax

Practice location:
  • Phone: 386-873-4740
  • Fax: 386-873-4742
Mailing address:
  • Phone: 386-873-4740
  • Fax: 386-873-4742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME56648
License Number StateFL

VIII. Authorized Official

Name: MRS. STACI G LEWIS
Title or Position: BILLER
Credential:
Phone: 386-873-4740