Provider Demographics
NPI:1235623505
Name:ROSEBERRY, FARRELL LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:FARRELL
Middle Name:LEE
Last Name:ROSEBERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 W 16TH ST UNIT D
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-0842
Mailing Address - Country:US
Mailing Address - Phone:928-348-1600
Mailing Address - Fax:
Practice Address - Street 1:2175 W 16TH ST UNIT D
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-0842
Practice Address - Country:US
Practice Address - Phone:928-348-1600
Practice Address - Fax:844-271-2379
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ009124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program