Provider Demographics
NPI:1528020856
Name:BANUELOS, ROSA MARIA (MD)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:MARIA
Last Name:BANUELOS
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:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85147-0002
Mailing Address - Country:US
Mailing Address - Phone:520-796-2600
Mailing Address - Fax:602-528-1296
Practice Address - Street 1:3041 W. QUEEN CREEK RD.
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286
Practice Address - Country:US
Practice Address - Phone:520-796-2600
Practice Address - Fax:602-528-1255
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20230207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ22506OtherGROUP BILLING PROVIDER
AZF39800Medicare UPIN
AZ106579Medicare PIN