Provider Demographics
NPI:1295761948
Name:ROSALES, JOSE J (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:J
Last Name:ROSALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 TOWN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8360
Mailing Address - Country:US
Mailing Address - Phone:386-775-8229
Mailing Address - Fax:386-775-2270
Practice Address - Street 1:1035 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8360
Practice Address - Country:US
Practice Address - Phone:386-775-8229
Practice Address - Fax:386-775-2270
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 71082207Q00000X, 207QA0000X, 207QA0505X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31498OtherBLUE CROSS BLUE SHIELD FL
FL31498OtherBLUE CROSS BLUE SHIELD FL
FL31498XMedicare PIN