Healthcare Provider Details

I. General information

NPI: 1982149001
Provider Name (Legal Business Name): ROBERTA S ROSE DO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8005 BAY ST SUITE 3
SEBASTIAN FL
32958-3244
US

IV. Provider business mailing address

8005 BAY ST SUITE 3
SEBASTIAN FL
32958-3244
US

V. Phone/Fax

Practice location:
  • Phone: 772-388-1100
  • Fax: 772-918-8834
Mailing address:
  • Phone: 772-388-1100
  • Fax: 772-918-8834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberOS6236
License Number StateFL

VIII. Authorized Official

Name: SHARON GORE
Title or Position: OFFICE MANAGER
Credential:
Phone: 772-388-1100