Provider Demographics
NPI:1316479603
Name:ROSADO, IVAN HORACIO (MD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:HORACIO
Last Name:ROSADO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1637 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-5823
Mailing Address - Country:US
Mailing Address - Phone:619-205-1360
Mailing Address - Fax:
Practice Address - Street 1:1637 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-5823
Practice Address - Country:US
Practice Address - Phone:619-205-1360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA169434207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program