Provider Demographics
NPI:1669530218
Name:ROSKIN, STACY DANA (MD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:DANA
Last Name:ROSKIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225 NE 167TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-3847
Mailing Address - Country:US
Mailing Address - Phone:786-480-5705
Mailing Address - Fax:
Practice Address - Street 1:3435 NE 163RD ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-4426
Practice Address - Country:US
Practice Address - Phone:786-480-5707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74069207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG65096Medicare UPIN
FL42355Medicare ID - Type Unspecified