Provider Demographics
NPI:1649391160
Name:ROSSELLO, JORGE ANTONIO JR (DO)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:ANTONIO
Last Name:ROSSELLO
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 CENTERGATE DR
Mailing Address - Street 2:#107
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-7213
Mailing Address - Country:US
Mailing Address - Phone:954-432-5559
Mailing Address - Fax:
Practice Address - Street 1:2430 CENTERGATE DR
Practice Address - Street 2:#107
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-7213
Practice Address - Country:US
Practice Address - Phone:954-432-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO4931156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician