Provider Demographics
NPI:1548335854
Name:ROSA, ANTONIO A (MD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:A
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 1:1215 W WHEELER PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1899
Mailing Address - Country:US
Mailing Address - Phone:706-868-1906
Mailing Address - Fax:706-868-0150
Practice Address - Street 1:1215 W WHEELER PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1899
Practice Address - Country:US
Practice Address - Phone:706-868-1906
Practice Address - Fax:706-868-0150
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61412970208000000X
GA051268208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000953004BMedicaid
WA2238141Medicaid