Provider Demographics
NPI:1790829885
Name:ROSALY, WILLIAM EDGARDO
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:EDGARDO
Last Name:ROSALY
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 1:1110 CALLE VILLA
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00728-4579
Mailing Address - Country:US
Mailing Address - Phone:787-284-2113
Mailing Address - Fax:787-284-2113
Practice Address - Street 1:CARR 132 KM 24 3
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00728-4579
Practice Address - Country:US
Practice Address - Phone:787-284-2113
Practice Address - Fax:787-284-2113
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR883291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
0031013Medicare ID - Type Unspecified