=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982740585
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA R ROSE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 03/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 E ALTAMONTE DR STE 1000
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32701-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-349-7917
-----------------------------------------------------
Fax | 407-349-7917
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 303 E ALTAMONTE DR STE 1000
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32701-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-349-7917
-----------------------------------------------------
Fax | 407-349-7917
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME93262
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------