Provider Demographics
NPI:1548244122
Name:ROSE, CARY (MD)
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 551308
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1308
Mailing Address - Country:US
Mailing Address - Phone:904-622-9040
Mailing Address - Fax:904-309-5690
Practice Address - Street 1:205 ZEAGLER DR STE 101
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3860
Practice Address - Country:US
Practice Address - Phone:904-493-3333
Practice Address - Fax:904-493-2222
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47083207RC0000X
TXP7558207RC0000X, 207RC0001X, 2085R0202X
IA37063207RC0000X, 207RC0001X
FLME138201207RC0001X
NMMD2022-0044207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0740571Medicaid
WI34679800Medicaid
MN024064800Medicaid
FL105189400Medicaid
IAI19245Medicare PIN