Basic Information
| Provider Information | |||||||||
| NPI: | 1366420986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSANOVA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2675 WINKLER AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339019342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13691 METRO PKWY STE 130 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339124321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393493539 | ||||||||
| FaxNumber: | 2392177469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036094420 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036094420 | 05 | IL | MEDICAID |