Healthcare Provider Details

I. General information

NPI: 1720181357
Provider Name (Legal Business Name): VIRGINIO RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: V RODRIGUEZ III MD PA

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 386-677-8880
  • Fax: 386-677-9880
Mailing address:
  • Phone: 386-677-8880
  • Fax: 386-677-9880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME566488
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: