Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RG0300X | Geriatric Medicine | 117175 | MO |
NPI | 1114069168 |
---|---|
Provider Name | Dr. Maria C. Dela Rosa |
First Address | Springfield, MO 65801-2580 |
Second Address | Springfield, MO 65804-2201 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/02/2007 |
Last Update Date | 03/05/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
140715001 | (05) | AR |
203806203 | (05) | MO |
98644 | AR BLUE SHIELD # (01) | MO |
G42125 | (02) | MO |