Provider Demographics
NPI:1619035995
Name:DE LA ROSA, JOSE MANUEL (MD)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:MANUEL
Last Name:DE LA ROSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:M
Other - Last Name:DE LA ROSA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 8013
Mailing Address - Street 2:
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00792-8013
Mailing Address - Country:US
Mailing Address - Phone:787-285-0115
Mailing Address - Fax:787-850-5711
Practice Address - Street 1:PLAZA DEL MAR SUITE
Practice Address - Street 2:1 ROAD 3 KM 86.5
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-285-0115
Practice Address - Fax:787-850-5711
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5123208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
C84169Medicare UPIN