Provider Demographics
NPI:1356553325
Name:ROSE, PAUL (LMT)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6924 STONESTHROW CIR N
Mailing Address - Street 2:8109
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-8736
Mailing Address - Country:US
Mailing Address - Phone:813-787-4133
Mailing Address - Fax:727-234-1980
Practice Address - Street 1:3601 W SWANN AVE
Practice Address - Street 2:105
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4547
Practice Address - Country:US
Practice Address - Phone:813-787-4133
Practice Address - Fax:727-341-1980
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0014113174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL688568396Medicaid
FL681650800Medicaid