Provider Demographics
NPI:1043271521
Name:ROBERT J. ROSE, MD
Entity type:Organization
Organization Name:ROBERT J. ROSE, MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-966-3672
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-0155
Mailing Address - Country:US
Mailing Address - Phone:209-966-3672
Mailing Address - Fax:209-966-5548
Practice Address - Street 1:5300 HWY 49N
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338
Practice Address - Country:US
Practice Address - Phone:209-966-3672
Practice Address - Fax:209-966-5548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01691ZOtherBLUE SHIELD PIN
CARHM53871FMedicaid
CACL737AMedicare PIN
CA553871Medicare ID - Type Unspecified
CARHM53871FMedicaid