Provider Demographics
NPI:1053529453
Name:BERNAL-LARIOZA, ROSE S (MD)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:S
Last Name:BERNAL-LARIOZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROSE MARICHELLE
Other - Middle Name:SANTOS
Other - Last Name:BERNAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:444 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01020-1969
Mailing Address - Country:US
Mailing Address - Phone:413-594-3111
Mailing Address - Fax:413-598-7040
Practice Address - Street 1:444 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-1969
Practice Address - Country:US
Practice Address - Phone:413-594-3111
Practice Address - Fax:413-598-7040
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA234525208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110080962/AMedicaid
MA110080962/AMedicaid