Provider Demographics
NPI:1982658118
Name:ROSALES, MARIANO L JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIANO
Middle Name:L
Last Name:ROSALES
Suffix:JR
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 1:600 FERN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1018
Mailing Address - Country:US
Mailing Address - Phone:920-324-3559
Mailing Address - Fax:920-324-0258
Practice Address - Street 1:600 FERN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1018
Practice Address - Country:US
Practice Address - Phone:920-324-3559
Practice Address - Fax:920-324-0258
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21906207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30219800Medicaid
WI22028Medicare ID - Type Unspecified
WIB56135Medicare UPIN