Healthcare Provider Details

I. General information

NPI: 1689742702
Provider Name (Legal Business Name): ROSA MARIA GIDOWSKI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 01/03/2013
Certification Date:
Deactivation Date: 09/17/2012
Reactivation Date: 12/26/2012

III. Provider practice location address

368 W BADILLO ST
COVINA CA
91723-2212
US

IV. Provider business mailing address

368 W BADILLO ST
COVINA CA
91723-2212
US

V. Phone/Fax

Practice location:
  • Phone: 626-915-5161
  • Fax: 626-915-5162
Mailing address:
  • Phone: 626-915-5161
  • Fax: 626-915-5162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA53575
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA53575
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: