Basic Information
| Provider Information | |||||||||
| NPI: | 1174503643 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUES | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARTIN | ||||||||
| OtherFirstName: | LORI | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3580 LAKE WORTH RD | ||||||||
| Address2: | |||||||||
| City: | PALM SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334614029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614255085 | ||||||||
| FaxNumber: | 5614295167 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 PIDGEON HILL DRIVE | ||||||||
| Address2: | STE. 130 | ||||||||
| City: | STERLING | ||||||||
| State: | VA | ||||||||
| PostalCode: | 20165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034441144 | ||||||||
| FaxNumber: | 7034446679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0101237660 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01018526 | 05 | VA | MEDICAID |