Provider Demographics
NPI:1447211263
Name:ROSA, UTE WAGNER (MD)
Entity Type:Individual
Prefix:
First Name:UTE
Middle Name:WAGNER
Last Name:ROSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PIERREPONT ST APT 3C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-7204
Mailing Address - Country:US
Mailing Address - Phone:718-643-7179
Mailing Address - Fax:
Practice Address - Street 1:20 PIERREPONT ST APT 3C
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-7204
Practice Address - Country:US
Practice Address - Phone:718-643-7179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129335207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01170323Medicaid
C98063Medicare UPIN
NY01170323Medicaid