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General NPI Number Information
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NPI Number | 1083622633
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Entity Type | Organization
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Legal Business Name | MY CHILDREN'S DOCTOR
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Dates
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Enumeration Date | 08/03/2006
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Last Update Date | 09/30/2011
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Provider Practice Location Address
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Address Line | 2484 CARING WAY SUITE D
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City | PORT CHARLOTTE
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State | FL
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Zip | 33952-6729
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Country | US
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Telephone | 941-625-1999
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Fax | 941-625-4600
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Provider Business Mailing Address
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Address Line | 2484 CARING WAY SUITE D
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City | PORT CHARLOTTE
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State | FL
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Zip | 33952-5306
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Country | US
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Telephone | 941-625-1999
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Fax | 941-625-4600
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Authorized Official
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Title or Position | CEO
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Name | DR. LUIS R RODRIGUEZ
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Credential | M.D.
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Telephone | 941-625-1999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME62983
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License Number State | FL
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