Healthcare Provider Details

I. General information

NPI: 1629085873
Provider Name (Legal Business Name): ROBERT J ROSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 HIGHWAY 49 NORTH
MARIPOSA CA
95338-1569
US

IV. Provider business mailing address

PO BOX 3768
MERCED CA
95344-3768
US

V. Phone/Fax

Practice location:
  • Phone: 209-966-3672
  • Fax: 209-966-5548
Mailing address:
  • Phone: 209-725-7149
  • Fax: 209-726-0134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG52454
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: