Provider Demographics
NPI:1629117916
Name:ROSA, MARILIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARILIN
Middle Name:
Last Name:ROSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARILIN
Other - Middle Name:
Other - Last Name:ROSA GALLARDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH STREET
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209
Practice Address - Country:US
Practice Address - Phone:904-244-5326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40064207ZC0500X
FLME98521207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2814081-00Medicaid
GA357175204AMedicaid
FLBH059ZMedicare PIN
GA357175204AMedicaid