Basic Information
| Provider Information | |||||||||
| NPI: | 1356714661 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ CASTRO | ||||||||
| FirstName: | IRELIS | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 S ORANGE AVE STE 940 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328013234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076589687 | ||||||||
| FaxNumber: | 4076589688 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 S CHARLES RICHARD BEALL BLVD | ||||||||
| Address2: | |||||||||
| City: | DEBARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327133342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3865160930 | ||||||||
| FaxNumber: | 3866686997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2015 | ||||||||
| LastUpdateDate: | 01/18/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 19228 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN881 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | ACN881 | 01 | FL | MEDICAL LICENSE | OTHER | FR5652284 | 01 | FL | DEA | OTHER |