Healthcare Provider Details

I. General information

NPI: 1053380634
Provider Name (Legal Business Name): RICHARD K.T. ROSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 12/02/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9961 SIERRA AVE MOB # 3
FONTANA CA
92335-6720
US

IV. Provider business mailing address

9961 SIERRA AVE MOB #3
FONTANA CA
92335-6720
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-4549
  • Fax: 909-427-7086
Mailing address:
  • Phone: 909-427-5611
  • Fax: 909-427-7086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD12937
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA71631
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberMD12937
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD12937
License Number StateHI
# 5
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberMD12937
License Number StateHI
# 6
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberA71631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: