Healthcare Provider Details

I. General information

NPI: 1912395807
Provider Name (Legal Business Name): SAMUEL JESUS ROSERO GARCIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2014
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W. WHITE MOUNTAIN BLVD, SUITE D
LAKESIDE AZ
85929
US

IV. Provider business mailing address

300 W. WHITE MOUNTAIN BLVD, SUITE D
LAKESIDE AZ
85929
US

V. Phone/Fax

Practice location:
  • Phone: 928-368-4547
  • Fax: 928-368-4527
Mailing address:
  • Phone: 928-368-4547
  • Fax: 928-368-4527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number61056
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number61056
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number019230
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: