Provider Demographics
NPI:1679989032
Name:VENTURA MONDRAGON, ROSALYNN (MD)
Entity type:Individual
Prefix:
First Name:ROSALYNN
Middle Name:
Last Name:VENTURA MONDRAGON
Suffix:
Gender:F
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:PO BOX 4189
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-4189
Mailing Address - Country:US
Mailing Address - Phone:954-363-9582
Mailing Address - Fax:954-363-9663
Practice Address - Street 1:3505 E HILLSBOROUGH AVE STE 101
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4547
Practice Address - Country:US
Practice Address - Phone:813-415-0100
Practice Address - Fax:813-415-0200
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1165208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106537400Medicaid