Provider Demographics
NPI:1104960665
Name:ROSE, ELI (MD)
Entity type:Individual
Prefix:DR
First Name:ELI
Middle Name:
Last Name:ROSE
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 1:3905 E EDEN ROC CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-7417
Mailing Address - Country:US
Mailing Address - Phone:813-886-7265
Mailing Address - Fax:813-886-6731
Practice Address - Street 1:2801 S MACDILL AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-7223
Practice Address - Country:US
Practice Address - Phone:813-871-6465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23218207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAR6520870OtherDEA
FLD58412Medicare UPIN
FLAR6520870OtherDEA