Healthcare Provider Details

I. General information

NPI: 1144289760
Provider Name (Legal Business Name): MILLA SERGEERNA ROSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 E 15TH ST
DOUGLAS AZ
85607-1631
US

IV. Provider business mailing address

1205 F AVE
DOUGLAS AZ
85607-1920
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-5437
  • Fax: 520-364-4261
Mailing address:
  • Phone: 520-364-1429
  • Fax: 520-364-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number31249
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: