Provider Demographics
NPI:1932274867
Name:ROSA, MARK A (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:ROSA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:ROSA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:23300 SUNNYMEAD BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-4533
Mailing Address - Country:US
Mailing Address - Phone:951-242-3937
Mailing Address - Fax:951-247-4649
Practice Address - Street 1:23300 SUNNYMEAD BLVD STE A
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-4533
Practice Address - Country:US
Practice Address - Phone:951-242-3937
Practice Address - Fax:951-247-4649
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8575T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA120022Medicare UPIN
CACE096AMedicare PIN
CA1932274867Medicare NSC