Healthcare Provider Details

I. General information

NPI: 1104928647
Provider Name (Legal Business Name): JOEL BERNARD ROSE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 WEBB RD SUITE 207
TAMPA FL
33615-2872
US

IV. Provider business mailing address

PO BOX 261748
TAMPA FL
33685-1748
US

V. Phone/Fax

Practice location:
  • Phone: 813-882-3331
  • Fax: 813-885-6209
Mailing address:
  • Phone: 813-882-3331
  • Fax: 813-885-6209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberOS 4694
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: