Provider Demographics
NPI:1023166535
Name:SAN GABRIEL, ROSVIDA ANNE B (MD)
Entity type:Individual
Prefix:DR
First Name:ROSVIDA
Middle Name:ANNE B
Last Name:SAN GABRIEL
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:104 W 6TH ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-2899
Mailing Address - Country:US
Mailing Address - Phone:815-673-2353
Mailing Address - Fax:815-673-2486
Practice Address - Street 1:104 W 6TH ST
Practice Address - Street 2:SUITE 303
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2899
Practice Address - Country:US
Practice Address - Phone:815-673-2353
Practice Address - Fax:815-673-2486
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2014-12-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036091951208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091951Medicaid
IL036091951Medicaid