Provider Demographics
NPI:1447272323
Name:ROSE, RICHARD SUN KYU KWAN (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:SUN KYU KWAN
Last Name:ROSE
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 1:500 FOOTHILL DR
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84148-0001
Mailing Address - Country:US
Mailing Address - Phone:801-582-1565
Mailing Address - Fax:801-584-2576
Practice Address - Street 1:500 FOOTHILL DR
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:801-584-2576
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5756670-1205207R00000X
WAMD60136118207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9370535OtherAETNA
WA1447272323Medicaid
WA0211ROOtherREGENCE
WA0260516OtherL&I AND CRIME VICTIMS
WA8567380Medicaid
WA0260516OtherL&I AND CRIME VICTIMS