Provider Demographics
NPI:1831190248
Name:ROSE, ROBERTA S (DO)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:S
Last Name:ROSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:S
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:13000 US HIGHWAY 1 STE 3
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3773
Mailing Address - Country:US
Mailing Address - Phone:772-388-1100
Mailing Address - Fax:772-918-8834
Practice Address - Street 1:13000 US HIGHWAY 1 STE 3
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3773
Practice Address - Country:US
Practice Address - Phone:772-388-1100
Practice Address - Fax:772-918-8834
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0S00062362084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80585AMedicare PIN
FLE54231Medicare UPIN