Provider Demographics
NPI:1245586775
Name:ROSE, JUSTIN ANDREW (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ANDREW
Last Name:ROSE
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 1:11945 SAN JOSE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:
Practice Address - Street 1:1370 13TH AVE S STE 116
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3206
Practice Address - Country:US
Practice Address - Phone:904-247-3858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT14510208600000X
FLOS19892208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery