=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083667984
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAYMOND E DE LA ROSA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 09/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8383 S TAMIAMI TRL UNIT 115
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34238-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-841-4206
-----------------------------------------------------
Fax | 941-841-4209
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2675 WINKLER AVE FL 2
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33901-9342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-856-3774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | ME132402
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------