Provider Demographics
NPI:1962446070
Name:ROSALES, MARK A (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:ROSALES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1027
Mailing Address - Country:US
Mailing Address - Phone:573-859-3775
Mailing Address - Fax:573-859-3997
Practice Address - Street 1:100 HIGHWAY 28 E
Practice Address - Street 2:
Practice Address - City:BELLE
Practice Address - State:MO
Practice Address - Zip Code:65013-3405
Practice Address - Country:US
Practice Address - Phone:573-859-3775
Practice Address - Fax:573-859-3997
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113794207QH0002X
MODO113794207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCC7852OtherRR GROUP
MOP00325210OtherRAILROAD
MO248871204Medicaid
MOF58419Medicare UPIN
MOCC7852OtherRR GROUP
MO001015063Medicare PIN
MO003012656Medicare PIN