Provider Demographics
NPI:1013020072
Name:ROSE, VIVIAN PERCIVAL (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:PERCIVAL
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-8921
Mailing Address - Country:US
Mailing Address - Phone:954-575-4040
Mailing Address - Fax:954-575-4049
Practice Address - Street 1:1505 N UNIVERSITY DR
Practice Address - Street 2:SUITE 300
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-8921
Practice Address - Country:US
Practice Address - Phone:954-575-4040
Practice Address - Fax:954-575-4049
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0043686174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD63185Medicare UPIN