Provider Demographics
NPI:1720288079
Name:CARRASCO, ROSARIO A (MD)
Entity Type:Individual
Prefix:
First Name:ROSARIO
Middle Name:A
Last Name:CARRASCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SISTER MAURA ROSARIO
Other - Middle Name:
Other - Last Name:CARRASCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7861
Mailing Address - Fax:207-298-0210
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-4735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125063940207R00000X
NH236972085R0202X
IL036-1487722085R0202X
MEMD266942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1710288079Medicaid