Provider Demographics
NPI:1649353723
Name:ROSALES, EDMUNDO (MD)
Entity type:Individual
Prefix:
First Name:EDMUNDO
Middle Name:
Last Name:ROSALES
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 1:1575 N RESLER DR STE D
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-8002
Mailing Address - Country:US
Mailing Address - Phone:910-676-2509
Mailing Address - Fax:919-439-3048
Practice Address - Street 1:1575 N RESLER DR STE D
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-8002
Practice Address - Country:US
Practice Address - Phone:915-271-4569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16949207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000BKFXJMedicare PIN