Basic Information
| Provider Information | |||||||||
| NPI: | 1538164157 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 6TH ST S | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278936116 | ||||||||
| FaxNumber: | 7275537340 | ||||||||
| Practice Location | |||||||||
| Address1: | 6775 CROSSWINDS DR N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337105471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273818006 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 03/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | ME82799 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | ME82799 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 265512800 | 05 | FL | MEDICAID |