Provider Demographics
NPI:1063461127
Name:ROSE, DONALD L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:L
Last Name:ROSE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 SW 3RD ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-6934
Mailing Address - Country:US
Mailing Address - Phone:954-941-4388
Mailing Address - Fax:954-941-4389
Practice Address - Street 1:550 SW 3RD ST
Practice Address - Street 2:SUITE 304
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-6934
Practice Address - Country:US
Practice Address - Phone:954-941-4388
Practice Address - Fax:954-941-4389
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3878103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPY0003878OtherSTATE / COUNTY
FL73326Medicare ID - Type Unspecified
FLOTH000Medicare UPIN