Basic Information
Provider Information | |||||||||
NPI: | 1831584747 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSE | ||||||||
FirstName: | CIELO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 15349 | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 323175349 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8505237410 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1264 METROPOLITAN BLVD | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 323122536 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8505237410 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/30/2015 | ||||||||
LastUpdateDate: | 05/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS13265 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 150KJ | 01 | FL | FL BLUE | OTHER | 015041300 | 05 | FL |   | MEDICAID |