Provider Demographics
NPI:1689764995
Name:ROSA, IVELISSE (DPM)
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:ROSA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 HEALD WAY BLDG 100
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32163-6087
Mailing Address - Country:US
Mailing Address - Phone:352-259-1919
Mailing Address - Fax:352-259-2042
Practice Address - Street 1:340 HEALD WAY BLDG 100
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32163-6087
Practice Address - Country:US
Practice Address - Phone:352-259-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00288300213ES0131X
NYN006138213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV09067Medicare UPIN