Provider Demographics
NPI:1043941255
Name:RODRIGUEZ, JUAN CARLOS (DOM)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4834 SAN PALERMO DR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-2366
Mailing Address - Country:US
Mailing Address - Phone:941-225-0198
Mailing Address - Fax:
Practice Address - Street 1:4834 SAN PALERMO DR
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-2366
Practice Address - Country:US
Practice Address - Phone:941-225-0198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP4124171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty