MEDICARE: MR. LUIS G RODAS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA9100841	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA9100841	OTHER	FL	PHYSICIAN ASSISTANT LIC.

General Provider Information

NPI Number	:	1609879360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LUIS G RODAS PA

Provider Business Mailing Address
First Line	:	9 NE 20TH AVE
Second Line	:	APT # 301
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33441-6114
Country	:	US
Telephone Number	:	954-429-1303
Fax Number	:	954-337-0157

Provider Business Practice Location Address
First Line	:	4001 N OCEAN DR
Second Line	:
City	:	LAUDERDALE BY THE SEA
State	:	FL
Zip	:	33308-5968
Country	:	US
Telephone Number	:	954-771-4000
Fax Number	:	954-776-0670

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	07/08/2007

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