Provider Demographics
NPI:1316905243
Name:ROSALES, VINCE BAUTISTA (MD)
Entity type:Individual
Prefix:
First Name:VINCE
Middle Name:BAUTISTA
Last Name:ROSALES
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 1:1242 AUGUSTA WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1854
Mailing Address - Country:US
Mailing Address - Phone:706-860-5000
Mailing Address - Fax:706-860-6544
Practice Address - Street 1:1242 AUGUSTA WEST PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1854
Practice Address - Country:US
Practice Address - Phone:706-860-5000
Practice Address - Fax:706-860-6544
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00830739BMedicaid
GA08BBXDDMedicare ID - Type Unspecified
GA00830739BMedicaid