=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053339606
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA ROSE MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 10/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3700 SUNSET LN SUITE 6
-----------------------------------------------------
City | ANTIOCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94509-6199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-755-8500
-----------------------------------------------------
Fax | 925-755-8200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11875 DUBLIN BLVD SUITE C140
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94568-2843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-587-2500
-----------------------------------------------------
Fax | 925-587-2511
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 25MA07624600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | A112131
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------