Basic Information
| Provider Information | |||||||||
| NPI: | 1750781936 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | WANDA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 S PINE ISLAND RD STE 800 | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333243923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052458050 | ||||||||
| FaxNumber: | 3052455950 | ||||||||
| Practice Location | |||||||||
| Address1: | 3084 NE 41ST TER | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330336619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052458050 | ||||||||
| FaxNumber: | 3052455950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2014 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 276519 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | ME147428 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 112554200 | 05 | FL | MEDICAID |