Basic Information
| Provider Information | |||||||||
| NPI: | 1609066778 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ISMAEL RODRIGUEZ M D P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1779 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320671779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042766977 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 KINGSLEY AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320735148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042768500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2007 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | RODRIGUEZ | ||||||||
| AuthorizedOfficialFirstName: | ISMAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9042766977 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M D P A | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | ME72759 | PR | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 270550800 | 05 | FL | MEDICAID |