Provider Demographics
NPI:1790742484
Name:MOSURE, ROGER ALLAN (ATC ETT LAT)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:ALLAN
Last Name:MOSURE
Suffix:
Gender:M
Credentials:ATC ETT LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 TIBERON COVE RD
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-2951
Mailing Address - Country:US
Mailing Address - Phone:407-332-6184
Mailing Address - Fax:
Practice Address - Street 1:6551LONGWOOD-LAKE MARY BLVD
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746
Practice Address - Country:US
Practice Address - Phone:407-320-9550
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00-170173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine