Provider Demographics
NPI:1831591585
Name:RODRIGUEZ, LISSET
Entity type:Individual
Prefix:
First Name:LISSET
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 S DIXIE HWY STE 207
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2200
Mailing Address - Country:US
Mailing Address - Phone:305-381-0485
Mailing Address - Fax:305-564-1660
Practice Address - Street 1:430 S DIXIE HWY STE 207
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2200
Practice Address - Country:US
Practice Address - Phone:053-810-4853
Practice Address - Fax:305-564-1660
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME128263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019-818-700Medicaid