Basic Information
| Provider Information | |||||||||
| NPI: | 1952397978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | DIANNE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4450 S TIFFANY DR | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334073241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618449443 | ||||||||
| FaxNumber: | 5618441013 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT PIERCE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349503975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724611402 | ||||||||
| FaxNumber: | 7724619795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 03/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME112772 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.