Healthcare Provider Details

I. General information

NPI: 1083008544
Provider Name (Legal Business Name): GRACIELENA RODRIGUEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 SE OCEAN BLVD STE 240
STUART FL
34994-3504
US

IV. Provider business mailing address

233 SW WHITMORE DR
PORT ST LUCIE FL
34984-3654
US

V. Phone/Fax

Practice location:
  • Phone: 561-626-9041
  • Fax:
Mailing address:
  • Phone: 786-333-1184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number143708
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: