1265869705 NPI number — VIRGINIO RODRIGUEZ III

Table of content: (NPI 1265869705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265869705 NPI number — VIRGINIO RODRIGUEZ III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIRGINIO RODRIGUEZ III
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
VR PEDIATRICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265869705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
345 CLYDE MORRIS BLVD STE 360
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORMOND BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32174-3114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-873-4740
Provider Business Mailing Address Fax Number:
386-873-4742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
345 CLYDE MORRIS BLVD STE 360
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORMOND BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32174-3114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-873-4740
Provider Business Practice Location Address Fax Number:
386-873-4742
Provider Enumeration Date:
09/30/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LEWIS
Authorized Official First Name:
STACI
Authorized Official Middle Name:
G
Authorized Official Title or Position:
BILLER
Authorized Official Telephone Number:
386-873-4740

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME56648 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 256164600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256164601 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".