Provider Demographics
NPI:1083667984
Name:DE LA ROSA, RAYMOND E (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:E
Last Name:DE LA ROSA
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:8383 S TAMIAMI TRL UNIT 115
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238-2901
Practice Address - Country:US
Practice Address - Phone:941-841-4206
Practice Address - Fax:941-841-4209
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME132402207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30918OtherSTATE LICENSE
KY64309180Medicaid
KY30918OtherSTATE LICENSE
G11366Medicare UPIN