Provider Demographics
NPI:1447245634
Name:MESOLA, ROVIE THERESA PATO (MD)
Entity Type:Individual
Prefix:DR
First Name:ROVIE THERESA
Middle Name:PATO
Last Name:MESOLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ROVIE
Other - Middle Name:
Other - Last Name:MESOLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:450 CLARKSON AVE
Mailing Address - Street 2:BOX 50
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2012
Mailing Address - Country:US
Mailing Address - Phone:917-733-4473
Mailing Address - Fax:
Practice Address - Street 1:450 CLARKSON AVE
Practice Address - Street 2:BOX 50
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2012
Practice Address - Country:US
Practice Address - Phone:917-733-4473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244938208M00000X
RIMD13057207R00000X
WAMD60103169207R00000X
MEMD21262207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02697890Medicaid
I46999Medicare UPIN
WAG8911589Medicare PIN