Healthcare Provider Details

I. General information

NPI: 1750736849
Provider Name (Legal Business Name): TREVINE ROSHAN ALBERT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7031 SW 62ND AVE
SOUTH MIAMI FL
33143-4701
US

IV. Provider business mailing address

4109 N FEDERAL HWY
FORT LAUDERDALE FL
33308-5530
US

V. Phone/Fax

Practice location:
  • Phone: 305-284-7500
  • Fax:
Mailing address:
  • Phone: 305-284-7775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS14935
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: