Provider Demographics
NPI:1487623112
Name:DE LA ROSA, CARLOS ALBERTO (OD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:ALBERTO
Last Name:DE LA ROSA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 HERRICK AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666
Mailing Address - Country:US
Mailing Address - Phone:212-926-0336
Mailing Address - Fax:212-926-0212
Practice Address - Street 1:3777 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1541
Practice Address - Country:US
Practice Address - Phone:212-926-0336
Practice Address - Fax:212-926-0212
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00534900152W00000X
NYTUV005619152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3087018Medicaid
NY01759824Medicaid
NY01759824Medicaid
U56167Medicare UPIN
NYC08491Medicare PIN