Provider Demographics
NPI:1275533531
Name:ROSANOVA, MARK ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:ROSANOVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:306 SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-3635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1478 HIGHLAND AVE STE A
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-6501
Practice Address - Country:US
Practice Address - Phone:321-242-2026
Practice Address - Fax:321-242-2423
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-067273207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31602264OtherBLUE CROSS BLUE SHIELD OF ILLINOIS
0001634901OtherBLUE CROSS BLUE SHIELD OF ILLINOIS
ILC41387Medicare UPIN
0001634901OtherBLUE CROSS BLUE SHIELD OF ILLINOIS