Healthcare Provider Details

I. General information

NPI: 1285890764
Provider Name (Legal Business Name): HEATHER J DUKES ROSALES DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 E CREEKS EDGE DR
BLOOMINGTON IN
47401-8368
US

IV. Provider business mailing address

2605 E CREEKS EDGE DR
BLOOMINGTON IN
47401-8368
US

V. Phone/Fax

Practice location:
  • Phone: 812-355-2300
  • Fax: 812-355-2302
Mailing address:
  • Phone: 812-355-2300
  • Fax: 812-355-2302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number02003675A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: