Provider Demographics
NPI:1952671323
Name:ROSALES, EWALDO PAUL LEYBA
Entity Type:Individual
Prefix:
First Name:EWALDO PAUL
Middle Name:LEYBA
Last Name:ROSALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 AIRPORT RD S
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34104-4351
Mailing Address - Country:US
Mailing Address - Phone:239-435-0454
Mailing Address - Fax:
Practice Address - Street 1:1565 AIRPORT RD S
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34104
Practice Address - Country:US
Practice Address - Phone:239-435-0454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1639186620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109849700Medicaid