Healthcare Provider Details

I. General information

NPI: 1629338231
Provider Name (Legal Business Name): VICTORIA SUMMER ROSE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2012
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1613 ROUTE 47 UNIT G
RIO GRANDE NJ
08242
US

IV. Provider business mailing address

1613 ROUTE 47 UNIT G
RIO GRANDE NJ
08242-1411
US

V. Phone/Fax

Practice location:
  • Phone: 609-886-5245
  • Fax: 609-886-5873
Mailing address:
  • Phone: 609-886-5245
  • Fax: 609-886-5873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD453908
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA10581300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: