Basic Information
| Provider Information | |||||||||
| NPI: | 1265689947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSALES | ||||||||
| FirstName: | CECILIA | ||||||||
| MiddleName: | MERCEDES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | STE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 10330 HICKMAN MILLS DR | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641371618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164127004 | ||||||||
| FaxNumber: | 8164127562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2008 | ||||||||
| LastUpdateDate: | 03/03/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZD0900X | 2002030859 | MO | Y | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZD0900X | 04-34708 | KS | N | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZD0900X | N4045 | TX | N | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | 200684050A | 05 | KS | MEDICAID | 1265689947 | 05 | MO | MEDICAID |