Provider Demographics
NPI:1639558216
Name:ROSALES, MARITZA BLANCA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARITZA
Middle Name:BLANCA
Last Name:ROSALES
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 1:444 NW ELKS DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3758
Mailing Address - Country:US
Mailing Address - Phone:541-754-1150
Mailing Address - Fax:
Practice Address - Street 1:601 HICKORY ST NW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321
Practice Address - Country:US
Practice Address - Phone:541-754-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD187370207Q00000X
VA0116027761207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine