Healthcare Provider Details

I. General information

NPI: 1033219811
Provider Name (Legal Business Name): MR. IRWIN W ROSADO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA PONCE OUTPATIENT CLINIC PASEO DEL VETERANO 1010
PONCE PR
00716-2001
US

IV. Provider business mailing address

159 CALLE A URB. LA VEGA
VILLALBA PR
00766-1716
US

V. Phone/Fax

Practice location:
  • Phone: 787-812-3030
  • Fax: 787-651-4321
Mailing address:
  • Phone: 787-847-4272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number047
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: