Provider Demographics
NPI:1619900438
Name:LA ROSA, CHARLES A (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name: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 1:15 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7381
Mailing Address - Country:US
Mailing Address - Phone:631-581-4400
Mailing Address - Fax:631-277-3750
Practice Address - Street 1:15 PARK AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7381
Practice Address - Country:US
Practice Address - Phone:631-581-4400
Practice Address - Fax:631-277-3750
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1673442086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY167344OtherLICENSE
NY01480831Medicaid
F79009Medicare UPIN
NY167344OtherLICENSE
NYF79009Medicare UPIN
07J951Medicare ID - Type Unspecified