Provider Demographics
NPI:1407830276
Name:DE LA ROSA, CINDY GRACE (MD)
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:GRACE
Last Name:DE LA ROSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:200 SAINT CLAIR AVE
Mailing Address - Street 2:JTDM FAMILY PRACTICE, LLC
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2400
Mailing Address - Country:US
Mailing Address - Phone:419-394-3387
Mailing Address - Fax:419-586-8509
Practice Address - Street 1:801 PRO DR
Practice Address - Street 2:GRAND LAKE FAMILY PRACTICE & PEDIATRICS
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-3307
Practice Address - Country:US
Practice Address - Phone:419-394-3387
Practice Address - Fax:419-586-8509
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2014-09-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35.092951208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9934723OtherGROUP PTAN
OH1942630348OtherGROUP NPI - GRAND LAKE FAMILY PRACTICE & PEDIATRICS
OH2927613Medicaid
OH9278851OtherMEDICARE PTAN LOCATION