Healthcare Provider Details

I. General information

NPI: 1982626719
Provider Name (Legal Business Name): OTTILIE T ROSE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 PERSHING DR
DERBY CT
06418-1433
US

IV. Provider business mailing address

78 PERSHING DR
DERBY CT
06418-1433
US

V. Phone/Fax

Practice location:
  • Phone: 203-709-8873
  • Fax: 203-709-8689
Mailing address:
  • Phone: 203-709-8873
  • Fax: 203-709-8689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number030635
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: