Provider Demographics
NPI:1629088281
Name:ROSE, THEODORE G (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:G
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1571 N. COAST HWY
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651
Mailing Address - Country:US
Mailing Address - Phone:510-847-8897
Mailing Address - Fax:510-437-5042
Practice Address - Street 1:12462 BROOKHURST ST A & B
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840
Practice Address - Country:US
Practice Address - Phone:716-636-9852
Practice Address - Fax:714-636-1248
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2025-08-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA24727207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A247270Medicaid
CA00A247270Medicaid
F15360Medicare UPIN