Healthcare Provider Details

I. General information

NPI: 1073503330
Provider Name (Legal Business Name): JEFFREY L ROSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 01/27/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1143 NW 64TH TER
GAINESVILLE FL
32605-4218
US

IV. Provider business mailing address

1143 NW 64TH TER
GAINESVILLE FL
32605-4218
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-1201
  • Fax: 352-331-5273
Mailing address:
  • Phone: 352-331-1201
  • Fax: 352-331-5273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number42922
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME0085249
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: