Provider Demographics
NPI:1447369558
Name:DELA ROSA, REYNALDO S (MD)
Entity type:Individual
Prefix:
First Name:REYNALDO
Middle Name:S
Last Name:DELA ROSA
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:337-470-2605
Mailing Address - Fax:
Practice Address - Street 1:4600 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6902
Practice Address - Country:US
Practice Address - Phone:337-470-2605
Practice Address - Fax:337-470-4595
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2026532080P0203X
IN010608592080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200529540Medicaid
MO207482605Medicaid
MS302I816792OtherMEDICARE PTAN
OH2869472Medicaid
IN200529540Medicaid
MO207482605Medicaid