Provider Demographics
NPI:1558374868
Name:DE LA ROSA, JOSE MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MANUEL
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:PO BOX 9520
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79995-9520
Mailing Address - Country:US
Mailing Address - Phone:915-545-9795
Mailing Address - Fax:915-545-9799
Practice Address - Street 1:4801 ALBERTA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2707
Practice Address - Country:US
Practice Address - Phone:915-545-6817
Practice Address - Fax:915-545-9799
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8073208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134465703Medicaid
TX8146J2Medicare ID - Type Unspecified
TX134465703Medicaid