Provider Demographics
NPI:1902804578
Name:MCCOY, ROSHA CHAMPION (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSHA
Middle Name:CHAMPION
Last Name:MCCOY
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 1:3501 JOHNSON ST
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-5421
Mailing Address - Country:US
Mailing Address - Phone:954-265-5045
Mailing Address - Fax:954-265-3464
Practice Address - Street 1:3501 JOHNSON ST
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5421
Practice Address - Country:US
Practice Address - Phone:954-265-5045
Practice Address - Fax:954-265-3464
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96691208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F26154Medicare UPIN