Provider Demographics
NPI:1164781803
Name:SERRANO, ROSA
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:SERRANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 N ZARAGOZA RD STE A4
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7974
Mailing Address - Country:US
Mailing Address - Phone:915-629-9639
Mailing Address - Fax:915-261-7093
Practice Address - Street 1:1510 N ZARAGOZA RD STE A4
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7974
Practice Address - Country:US
Practice Address - Phone:915-629-9639
Practice Address - Fax:915-261-7093
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDR4124156FC0800X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX066324701Medicaid
5801560001Medicare NSC