Provider Demographics
NPI:1174800403
Name:BERROCAL RODRIGUEZ, EDNA I (OD)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:I
Last Name:BERROCAL RODRIGUEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:EDNA
Other - Middle Name:I
Other - Last Name:BERROCAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:4980 EAST COLONIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-4376
Mailing Address - Country:US
Mailing Address - Phone:407-895-6254
Mailing Address - Fax:407-992-9365
Practice Address - Street 1:4980 EAST COLONIAL DRIVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4376
Practice Address - Country:US
Practice Address - Phone:407-895-6254
Practice Address - Fax:407-992-9365
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002529152W00000X
FLOPC4888152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist