Provider Demographics
NPI:1053318931
Name:DE LA ROSA, ANTONIO IV (MD)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:DE LA ROSA
Suffix:IV
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 1:3270 JOE BATTLE BLVD
Mailing Address - Street 2:STE 275
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-2639
Mailing Address - Country:US
Mailing Address - Phone:915-271-4600
Mailing Address - Fax:915-271-4601
Practice Address - Street 1:3270 JOE BATTLE BLVD
Practice Address - Street 2:STE 275
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-2639
Practice Address - Country:US
Practice Address - Phone:915-271-4600
Practice Address - Fax:915-271-4601
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5299207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164276101Medicaid
I10863Medicare UPIN
TX164276101Medicaid