Basic Information
| Provider Information | |||||||||
| NPI: | 1366861874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESA | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | ROSNER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSNER | ||||||||
| OtherFirstName: | DANIELLE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4881 NW 8TH AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524161082 | ||||||||
| FaxNumber: | 3523736144 | ||||||||
| Practice Location | |||||||||
| Address1: | 4343 W NEWBERRY RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326072817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523785173 | ||||||||
| FaxNumber: | 3523752330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2014 | ||||||||
| LastUpdateDate: | 08/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | UO3980 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 390200000X | UO3980 | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 103472400 | 05 | FL | MEDICAID |