Provider Demographics
NPI:1982740585
Name:ROSE, LISA R (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:REGAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:303 E ALTAMONTE DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-4403
Mailing Address - Country:US
Mailing Address - Phone:407-349-7917
Mailing Address - Fax:407-349-7917
Practice Address - Street 1:303 E ALTAMONTE DR STE 1000
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-4403
Practice Address - Country:US
Practice Address - Phone:407-349-7917
Practice Address - Fax:407-349-7917
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93262207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274053200Medicaid
FLU7086ZMedicare ID - Type Unspecified
FL274053200Medicaid