Provider Demographics
NPI:1265869705
Name:VIRGINIO RODRIGUEZ III
Entity type:Organization
Organization Name:VIRGINIO RODRIGUEZ III
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACI
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-873-4740
Mailing Address - Street 1:345 CLYDE MORRIS BLVD STE 360
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-3114
Mailing Address - Country:US
Mailing Address - Phone:386-873-4740
Mailing Address - Fax:386-873-4742
Practice Address - Street 1:345 CLYDE MORRIS BLVD STE 360
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-3114
Practice Address - Country:US
Practice Address - Phone:386-873-4740
Practice Address - Fax:386-873-4742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56648208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256164600Medicaid
FL256164601Medicaid