Provider Demographics
NPI:1528024908
Name:DE LA ROSA, JUAN ANGEL (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:ANGEL
Last Name:DE LA ROSA
Suffix:
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:URB. CAMINO DEL SOL
Mailing Address - Street 2:420 CAMINO REAL
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693-4177
Mailing Address - Country:US
Mailing Address - Phone:787-807-5437
Mailing Address - Fax:
Practice Address - Street 1:URB. CAMINO DEL SOL
Practice Address - Street 2:420 CAMINO REAL
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-4177
Practice Address - Country:US
Practice Address - Phone:787-807-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2176650172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR14417OtherLICENSE
PRI-06423Medicare UPIN
PR0022403Medicare ID - Type Unspecified