Healthcare Provider Details

I. General information

NPI: 1972579043
Provider Name (Legal Business Name): LOURDES DELA ROSA MONSOD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 12/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 W LOWDER ST
MACCLENNY FL
32063-2664
US

IV. Provider business mailing address

2585 MERCHANTS ROW BLVD BIN A05
TALLAHASSEE FL
32311-3645
US

V. Phone/Fax

Practice location:
  • Phone: 904-259-6291
  • Fax: 904-259-4761
Mailing address:
  • Phone: 904-259-6291
  • Fax: 904-259-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME39603
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: