Healthcare Provider Details

I. General information

NPI: 1033408646
Provider Name (Legal Business Name): ROSANTO AGPAOA MACAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 N WICKHAM RD SUITE 304
MELBOURNE FL
32935-8662
US

IV. Provider business mailing address

1004 BEVERLY DR SUITE F
ROCKLEDGE FL
32955-2840
US

V. Phone/Fax

Practice location:
  • Phone: 321-308-5060
  • Fax: 321-984-9497
Mailing address:
  • Phone: 321-637-2949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number109849
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: