Healthcare Provider Details

I. General information

NPI: 1376771444
Provider Name (Legal Business Name): PAUL RODRIGUEZ-WAITKUS MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13330 USF LAUREL DR FL 4
TAMPA FL
33612-6601
US

IV. Provider business mailing address

12901 BRUCE B DOWNS BLVD # 79
TAMPA FL
33612-4742
US

V. Phone/Fax

Practice location:
  • Phone: 813-974-3744
  • Fax:
Mailing address:
  • Phone: 813-974-3744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberME116289
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: