Provider Demographics
NPI:1598713976
Name:ROSA-OLIVARES, JOSE (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:ROSA-OLIVARES
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 557367
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33255-7367
Mailing Address - Country:US
Mailing Address - Phone:786-624-5845
Mailing Address - Fax:786-624-2688
Practice Address - Street 1:3100 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155
Practice Address - Country:US
Practice Address - Phone:305-669-6505
Practice Address - Fax:305-669-6447
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
FLME78113207P00000X, 208000000X, 207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No174400000XOther Service ProvidersSpecialist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258545600Medicaid