Provider Demographics
NPI:1942954078
Name:DAVIS ROSARIO, LISSETTE ANN MARIE
Entity Type:Individual
Prefix:DR
First Name:LISSETTE
Middle Name:ANN MARIE
Last Name:DAVIS ROSARIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. PUERTO NUEVO 1371 CALLE 12 NW
Mailing Address - Street 2:APT 4
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00920
Mailing Address - Country:US
Mailing Address - Phone:787-387-9520
Mailing Address - Fax:
Practice Address - Street 1:70 CALLE SANTA CRUZ
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-7052
Practice Address - Country:US
Practice Address - Phone:787-387-9520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16085I390200000X
PR23305208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program