Provider Demographics
NPI:1326772484
Name:ROSA, JOSE (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:ROSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4189
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-4189
Mailing Address - Country:US
Mailing Address - Phone:561-406-6080
Mailing Address - Fax:954-363-9663
Practice Address - Street 1:608 INGRAHAM AVE
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-4330
Practice Address - Country:US
Practice Address - Phone:863-422-9562
Practice Address - Fax:863-421-3246
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15811-I208D00000X
FLACN1502208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116450600Medicaid