Provider Demographics
NPI:1861453953
Name:ROSALES, MARK ANTHONY (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:ROSALES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 N HUMPHREYS ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4531
Mailing Address - Country:US
Mailing Address - Phone:928-774-9325
Mailing Address - Fax:888-464-1135
Practice Address - Street 1:421 N HUMPHREYS ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4531
Practice Address - Country:US
Practice Address - Phone:928-774-9325
Practice Address - Fax:888-464-1135
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0608213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1861453953OtherNPI
AZ934225-001Medicaid
AZAZ0195640OtherBC/BS ID#
Z118265OtherPTAN
6027370001Medicare NSC
AZAZ0195640OtherBC/BS ID#