Healthcare Provider Details

I. General information

NPI: 1275309932
Provider Name (Legal Business Name): DIVERSE MEDICAL PROFESSIONALS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S FEDERAL HWY STE 302
BOYNTON BEACH FL
33435-6058
US

IV. Provider business mailing address

1200 S FEDERAL HWY STE 302
BOYNTON BEACH FL
33435-6058
US

V. Phone/Fax

Practice location:
  • Phone: 561-509-9382
  • Fax: 561-509-9362
Mailing address:
  • Phone: 561-509-9382
  • Fax: 561-509-9362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RYAN ROSEN
Title or Position: PHYSICIAN/MEDICAL DIRECTOR
Credential: MD
Phone: 561-509-9382