Healthcare Provider Details

I. General information

NPI: 1003920117
Provider Name (Legal Business Name): VERNON ANTHONY ROSARIO II MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 E 120TH ST
LOS ANGELES CA
90059-3052
US

IV. Provider business mailing address

1720 E 120TH ST
LOS ANGELES CA
90059-3052
US

V. Phone/Fax

Practice location:
  • Phone: 310-668-3096
  • Fax: 310-223-0914
Mailing address:
  • Phone: 310-668-3096
  • Fax: 310-223-0914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA066651
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: