Provider Demographics
NPI:1417114737
Name:ROOSE, BRANDY MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDY
Middle Name:MICHELLE
Last Name:ROOSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1259 S PINELLAS AVE
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-3719
Mailing Address - Country:US
Mailing Address - Phone:727-938-1908
Mailing Address - Fax:727-938-8693
Practice Address - Street 1:1259 S PINELLAS AVE
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-3719
Practice Address - Country:US
Practice Address - Phone:727-938-1908
Practice Address - Fax:727-938-8693
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFM910ZMedicare PIN