1407830276 NPI number — CINDY GRACE DE LA ROSA M.D.

Table of content: CINDY GRACE DE LA ROSA M.D. (NPI 1407830276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407830276 NPI number — CINDY GRACE DE LA ROSA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LA ROSA
Provider First Name:
CINDY
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407830276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 SAINT CLAIR AVE
Provider Second Line Business Mailing Address:
JTDM FAMILY PRACTICE, LLC
Provider Business Mailing Address City Name:
SAINT MARYS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45885-2400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-394-3387
Provider Business Mailing Address Fax Number:
419-586-8509

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 PRO DR
Provider Second Line Business Practice Location Address:
GRAND LAKE FAMILY PRACTICE & PEDIATRICS
Provider Business Practice Location Address City Name:
CELINA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45822-3307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-394-3387
Provider Business Practice Location Address Fax Number:
419-586-8509
Provider Enumeration Date:
12/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  35.092951 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9934723 . This is a "GROUP PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1942630348 . This is a "GROUP NPI - GRAND LAKE FAMILY PRACTICE & PEDIATRICS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2927613 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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