Provider Demographics
NPI:1275597288
Name:ROSA, LOUIS III (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:ROSA
Suffix:III
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 1:4381 S EASON BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6583
Mailing Address - Country:US
Mailing Address - Phone:662-377-5700
Mailing Address - Fax:662-377-5720
Practice Address - Street 1:4381 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6583
Practice Address - Country:US
Practice Address - Phone:662-377-5700
Practice Address - Fax:662-377-5720
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16496207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08878817Medicaid
MS140000161Medicare ID - Type Unspecified
MS08878817Medicaid