Provider Demographics
NPI:1194245464
Name:ROSA CARRASQUILLO, MIGUEL JOSE
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:JOSE
Last Name:ROSA CARRASQUILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:768 CALLE ARRAYADO
Mailing Address - Street 2:URB SAN DEMETRIO
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693
Mailing Address - Country:US
Mailing Address - Phone:787-487-4742
Mailing Address - Fax:
Practice Address - Street 1:768 CALLE ARRAYADO
Practice Address - Street 2:URB SAN DEMETRIO
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-0069
Practice Address - Country:US
Practice Address - Phone:787-487-4742
Practice Address - Fax:787-487-4742
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14214I208D00000X
PR19735208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice