Provider Demographics
NPI:1023372612
Name:BACALA, JOSE ROSAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:ROSAS
Last Name:BACALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 98978
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8978
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:6850 N DURANGO DR
Practice Address - Street 2:SUITE 208
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-4595
Practice Address - Country:US
Practice Address - Phone:702-952-0999
Practice Address - Fax:702-952-0998
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301101427207Q00000X
NV16237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1023372612Medicaid
NVPENDINGMedicare PIN