Provider Demographics
NPI:1114966777
Name:DE LA ROSA, RENATO (MD)
Entity Type:Individual
Prefix:
First Name:RENATO
Middle Name:
Last Name:DE LA ROSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 MEDICAL CENTER CT STE 103
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6655
Mailing Address - Country:US
Mailing Address - Phone:619-397-5001
Mailing Address - Fax:619-397-4460
Practice Address - Street 1:754 MEDICAL CENTER CT STE 103
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6655
Practice Address - Country:US
Practice Address - Phone:619-397-5001
Practice Address - Fax:619-397-4460
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65330208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A653300Medicaid
CAH03444Medicare UPIN
CA00A653300Medicaid