Provider Demographics
NPI:1477560829
Name:ROSARIO, CARLOS M (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:M
Last Name:ROSARIO
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 1:690 VETERAN AVE
Mailing Address - Street 2:#208
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-1946
Mailing Address - Country:US
Mailing Address - Phone:310-443-8942
Mailing Address - Fax:
Practice Address - Street 1:1570 BROOKHOLLOW DR
Practice Address - Street 2:STE. 211
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5428
Practice Address - Country:US
Practice Address - Phone:866-322-4222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG858152084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Not Answered2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG85815Medicare ID - Type Unspecified
CAH80765Medicare UPIN