Provider Demographics
NPI:1023633468
Name:ROSARIO, MARIO IVAN (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:IVAN
Last Name:ROSARIO
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:HC 3 BOX 12360
Mailing Address - Street 2:
Mailing Address - City:CAMUY
Mailing Address - State:PR
Mailing Address - Zip Code:00627-9814
Mailing Address - Country:US
Mailing Address - Phone:787-356-3158
Mailing Address - Fax:
Practice Address - Street 1:CARR # 2 KM 94.1 BO. YEGUADA
Practice Address - Street 2:
Practice Address - City:CAMUY
Practice Address - State:PR
Practice Address - Zip Code:00627
Practice Address - Country:US
Practice Address - Phone:787-356-3158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21906208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice