Provider Demographics
NPI:1508199381
Name:ROSE, GAVIN ELLIOT (MD)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:ELLIOT
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1065 NE 125TH ST STE 409
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5834
Mailing Address - Country:US
Mailing Address - Phone:888-852-6672
Mailing Address - Fax:877-720-0502
Practice Address - Street 1:10301 HAGEN RANCH RD STE B6
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3723
Practice Address - Country:US
Practice Address - Phone:888-852-6672
Practice Address - Fax:561-752-9490
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME972532084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry