Provider Demographics
NPI:1093917015
Name:JOHN DELLA ROSA, MD
Entity Type:Organization
Organization Name:JOHN DELLA ROSA, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DELLA ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-331-2655
Mailing Address - Street 1:190 WELLES ST
Mailing Address - Street 2:SUITE 114
Mailing Address - City:FORTY FORT
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4969
Mailing Address - Country:US
Mailing Address - Phone:570-331-2655
Mailing Address - Fax:570-331-2671
Practice Address - Street 1:190 WELLES ST
Practice Address - Street 2:SUITE 114
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-4968
Practice Address - Country:US
Practice Address - Phone:570-331-2655
Practice Address - Fax:570-331-2671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030692E2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000945585004Medicaid
PA000945585004Medicaid
PA57903Medicare ID - Type Unspecified