Healthcare Provider Details

I. General information

NPI: 1548790231
Provider Name (Legal Business Name): KENNETH G ROSARIO-RODRIGUEZ JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 OAKFIELD DRIVE BRANDON FLORIDA 33511
BRANDON FL
33511
US

IV. Provider business mailing address

119 OAKFIELD DRIVE BRANDON FLORIDA
BRANDON FL
33511
US

V. Phone/Fax

Practice location:
  • Phone: 813-681-5551
  • Fax: 813-916-2944
Mailing address:
  • Phone: 813-681-5551
  • Fax: 813-916-2944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number332629
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: