Basic Information
| Provider Information | |||||||||
| NPI: | 1205031853 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | CARLOS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2721 DEL PRADO BLVD S STE 200 | ||||||||
| Address2: | |||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339045783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396739034 | ||||||||
| FaxNumber: | 2396739102 | ||||||||
| Practice Location | |||||||||
| Address1: | 2721 DEL PRADO BLVD S STE 200 | ||||||||
| Address2: | |||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339045783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396739034 | ||||||||
| FaxNumber: | 2396739102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2007 | ||||||||
| LastUpdateDate: | 09/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | ME60410 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 023711500 | 05 | FL | MEDICAID |