Provider Demographics
NPI:1770609554
Name:ROSATI, SAMUEL M (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:M
Last Name:ROSATI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 LUNA BELLA LN APT 235
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168
Mailing Address - Country:US
Mailing Address - Phone:716-434-2116
Mailing Address - Fax:
Practice Address - Street 1:424 LUNA BELLA LN APT 235
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168
Practice Address - Country:US
Practice Address - Phone:716-434-2116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103357207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL151A0OtherBCBS
FL1770609554OtherTRICARE
FL1770609554OtherTRICARE