Provider Demographics
NPI:1770898330
Name:BARRIOS-BANAL, MARY ROSE BAES (MD)
Entity type:Individual
Prefix:
First Name:MARY ROSE
Middle Name:BAES
Last Name:BARRIOS-BANAL
Suffix:
Gender:F
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:PO BOX 1137
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1137
Mailing Address - Country:US
Mailing Address - Phone:321-952-9696
Mailing Address - Fax:321-952-7937
Practice Address - Street 1:5270 BABCOCK ST NE
Practice Address - Street 2:SUITE 1
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-8630
Practice Address - Country:US
Practice Address - Phone:321-676-5996
Practice Address - Fax:321-676-5926
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME115781208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program