Provider Demographics
NPI:1245314392
Name:DE LA ROSA, MARITZA (MD)
Entity type:Individual
Prefix:
First Name:MARITZA
Middle Name:
Last Name:DE LA ROSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BAKLEY TER
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2169
Mailing Address - Country:US
Mailing Address - Phone:973-736-7179
Mailing Address - Fax:973-736-2456
Practice Address - Street 1:339 HICKS ST
Practice Address - Street 2:LONG ISLAND COLLEGE HOSPITAL- DEPT. OF FAMILY MEDICINE
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5509
Practice Address - Country:US
Practice Address - Phone:718-780-4997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1450480Medicaid
NY1450480Medicaid
NY06L551Medicare ID - Type Unspecified