Healthcare Provider Details

I. General information

NPI: 1487737979
Provider Name (Legal Business Name): MADELINE ROSARIO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30729 LYON CENTER DR E
NEW HUDSON MI
48165-8903
US

IV. Provider business mailing address

13537 COBBLESTONE CREEK DR
VAN BUREN TOWNSHIP MI
48111-2034
US

V. Phone/Fax

Practice location:
  • Phone: 248-486-3491
  • Fax:
Mailing address:
  • Phone: 734-757-9688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number245
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004939
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: