Healthcare Provider Details

I. General information

NPI: 1477973121
Provider Name (Legal Business Name): JORGE GABRIEL ROSADO GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD STE 5709
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

2608 LOUIS AVE
SAINT LOUIS MO
63144-2537
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5633
  • Fax:
Mailing address:
  • Phone: 314-532-1516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number2023027370
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: