MEDICARE: ROSA IVELISSE COLON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	9506	PR

General Provider Information

NPI Number	:	1346736444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSA IVELISSE COLON MD

Provider Business Mailing Address
First Line	:	6545 ROYAL RIDGE DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-7439
Country	:	US
Telephone Number	:	915-443-1553
Fax Number	:

Provider Business Practice Location Address
First Line	:	6545 ROYAL RIDGE DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-7439
Country	:	US
Telephone Number	:	915-443-1553
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2018
Last Update Date	:	07/02/2018

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