Provider Demographics
NPI:1396816179
Name:ROSE, TREVOR ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:ANTHONY
Last Name:ROSE
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 1:6551 RIDGE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-6868
Mailing Address - Country:US
Mailing Address - Phone:727-846-0666
Mailing Address - Fax:727-849-1474
Practice Address - Street 1:6551 RIDGE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-6868
Practice Address - Country:US
Practice Address - Phone:727-846-0666
Practice Address - Fax:727-849-1474
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME60120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF07359Medicare UPIN
FL12894Medicare ID - Type Unspecified