Provider Demographics
NPI:1942495866
Name:DE ROSAS, JUAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:
Last Name:DE ROSAS
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 ELIZABETH DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5226
Mailing Address - Country:US
Mailing Address - Phone:716-434-8802
Mailing Address - Fax:716-434-0093
Practice Address - Street 1:15 ELIZABETH DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5226
Practice Address - Country:US
Practice Address - Phone:716-434-8802
Practice Address - Fax:716-434-0093
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117428-1208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00616317Medicaid
NYRB5182Medicare PIN
NY00616317Medicaid