Healthcare Provider Details

I. General information

NPI: 1588718522
Provider Name (Legal Business Name): DESERT ROSE OBSTETRICS & GYNECOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 SOUTH AVE
SOUTH LAKE TAHOE CA
96150
US

IV. Provider business mailing address

P.O. BOX 2046
CARSON CITY NV
89702
US

V. Phone/Fax

Practice location:
  • Phone: 775-882-8487
  • Fax: 775-882-8487
Mailing address:
  • Phone: 775-882-8487
  • Fax: 775-882-8487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5413
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0116950
License Number StateNV

VIII. Authorized Official

Name: MATTHEW JOSEPH BARULICH III
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 775-846-5228