Healthcare Provider Details

I. General information

NPI: 1295429223
Provider Name (Legal Business Name): GREGORY ROSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46440 BENEDICT DR STE 209
STERLING VA
20164-6602
US

IV. Provider business mailing address

14010 SMOKETOWN RD STE 103
WOODBRIDGE VA
22192-4723
US

V. Phone/Fax

Practice location:
  • Phone: 703-583-5959
  • Fax: 703-583-5995
Mailing address:
  • Phone: 703-583-5959
  • Fax: 703-583-5995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103301491
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: