Provider Demographics
NPI:1326772484
Name:ROSA, JOSE (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:ROSA
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:URB. SANTA ISIDRA 3
Mailing Address - Street 2:A-18, CALLE B
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738
Mailing Address - Country:US
Mailing Address - Phone:787-719-1593
Mailing Address - Fax:
Practice Address - Street 1:CARR. 31 KM. 4.0
Practice Address - Street 2:
Practice Address - City:NAGUABO
Practice Address - State:PR
Practice Address - Zip Code:00718
Practice Address - Country:US
Practice Address - Phone:787-874-3152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15811-I208D00000X
FLACN1502208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116450600Medicaid