Provider Demographics
NPI:1750984043
Name:GONZALEZ DE LA ROSA, ROGELIO
Entity type:Individual
Prefix:
First Name:ROGELIO
Middle Name:
Last Name:GONZALEZ DE LA ROSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23037 SW 108TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33170-7538
Mailing Address - Country:US
Mailing Address - Phone:786-302-0569
Mailing Address - Fax:
Practice Address - Street 1:23037 SW 108TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33170-7538
Practice Address - Country:US
Practice Address - Phone:786-302-0569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness