Provider Demographics
NPI:1700876539
Name:ROSA, ROBERT C (O D)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:ROSA
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 WOLVERINE WAY
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5301
Mailing Address - Country:US
Mailing Address - Phone:760-940-6390
Mailing Address - Fax:
Practice Address - Street 1:11495 CARMEL MOUNTAIN RD
Practice Address - Street 2:102
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-4618
Practice Address - Country:US
Practice Address - Phone:858-675-0485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7774T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0077740Medicaid
ART59378Medicare UPIN
OP7774Medicare ID - Type Unspecified