Healthcare Provider Details

I. General information

NPI: 1962018671
Provider Name (Legal Business Name): JOSHUA ROOSE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22894 19 MILE RD
TUSTIN MI
49688-8059
US

IV. Provider business mailing address

22894 19 MILE RD
TUSTIN MI
49688-8059
US

V. Phone/Fax

Practice location:
  • Phone: 231-884-4462
  • Fax:
Mailing address:
  • Phone: 231-884-4462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number58.032115
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: