Basic Information
| Provider Information | |||||||||
| NPI: | 1689098527 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMACHO RODRIGUEZ | ||||||||
| FirstName: | MAELYN | ||||||||
| MiddleName: | LAZARA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331373795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055766611 | ||||||||
| FaxNumber: | 7864762819 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 W 49TH ST | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330123322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8446654827 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2014 | ||||||||
| LastUpdateDate: | 11/07/2019 | ||||||||
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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 | ACN569 | FL | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | 18593 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ME137603 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | ME137603 | 01 | FL | MEDICAL LICENSE | OTHER | 012354200 | 05 | FL | MEDICAID | ACN569 | 01 | FL | MEDICAL LICSENSE | OTHER | FC4636392 | 01 | FL | DEA LICENSE | OTHER |