Provider Demographics
NPI:1831209634
Name:ROSALES, CAMILO (MD)
Entity type:Individual
Prefix:
First Name:CAMILO
Middle Name:
Last Name:ROSALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3329
Mailing Address - Country:US
Mailing Address - Phone:503-325-4321
Mailing Address - Fax:
Practice Address - Street 1:2055 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3419
Practice Address - Country:US
Practice Address - Phone:503-338-4670
Practice Address - Fax:503-338-4671
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI6550174400000X
OR27153208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIE50833Medicare UPIN