Healthcare Provider Details

I. General information

NPI: 1669530218
Provider Name (Legal Business Name): STACY DANA ROSKIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 NE 163RD ST
NORTH MIAMI BEACH FL
33160-4426
US

IV. Provider business mailing address

3225 NE 167TH ST
NORTH MIAMI BEACH FL
33160-3847
US

V. Phone/Fax

Practice location:
  • Phone: 786-480-5707
  • Fax:
Mailing address:
  • Phone: 786-480-5705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME74069
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME74069
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: