Provider Demographics
NPI:1932151214
Name:HIDALGO-LAOS, ROSA I
Entity Type:Individual
Prefix:MS
First Name:ROSA
Middle Name:I
Last Name:HIDALGO-LAOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8774 PERIMETER PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6347
Mailing Address - Country:US
Mailing Address - Phone:904-642-6100
Mailing Address - Fax:
Practice Address - Street 1:4972 TOWN CENTER PKWY STE 301
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246
Practice Address - Country:US
Practice Address - Phone:904-642-6100
Practice Address - Fax:904-642-5154
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80754208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2602717-00Medicaid
FL260271700Medicaid
FL260271700Medicaid
FLH34958Medicare UPIN