Provider Demographics
NPI:1306130786
Name:ROSARIO, IRISSA WILSON (MD)
Entity type:Individual
Prefix:DR
First Name:IRISSA
Middle Name:WILSON
Last Name:ROSARIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:IRISSA
Other - Middle Name:N
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:51 PENNSYLVANIA ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2937
Mailing Address - Country:US
Mailing Address - Phone:321-843-3220
Mailing Address - Fax:321-843-3210
Practice Address - Street 1:51 PENNSYLVANIA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2937
Practice Address - Country:US
Practice Address - Phone:321-843-3220
Practice Address - Fax:321-843-3210
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME120306208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012775500Medicaid