Provider Demographics
NPI:1922148543
Name:ROS, IVAN (PTA)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:ROS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4430 SW 129TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-4039
Mailing Address - Country:US
Mailing Address - Phone:305-553-0127
Mailing Address - Fax:
Practice Address - Street 1:2869 SW 27TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-3701
Practice Address - Country:US
Practice Address - Phone:305-444-0074
Practice Address - Fax:305-444-8503
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA19569225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant