Healthcare Provider Details

I. General information

NPI: 1174695795
Provider Name (Legal Business Name): IVONNE ELIZABETH DE LA ROSA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IVONNE ELIZABETH MALDONADO

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 RUFFIN CT STE B
SAN DIEGO CA
92123-5399
US

IV. Provider business mailing address

3020 CHILDRENS WAY # MC5003
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-874-1033
  • Fax:
Mailing address:
  • Phone: 858-309-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA49734
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: