Provider Demographics
NPI:1073503330
Name:ROSE, JEFFREY L (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1143 NW 64TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4218
Mailing Address - Country:US
Mailing Address - Phone:352-331-1201
Mailing Address - Fax:352-331-5273
Practice Address - Street 1:1143 NW 64TH TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4218
Practice Address - Country:US
Practice Address - Phone:352-331-1201
Practice Address - Fax:352-331-5273
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO42922208600000X
FLME0085249208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
I14639Medicare UPIN