=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275740847
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINA DESOUSA ROSE M.D., M.P.H.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 10/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 S MAIN ST STE 502
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-4909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-702-8400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5141 OAKMAN BLVD
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48126-3763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-846-8840
-----------------------------------------------------
Fax | 313-846-1540
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 4301088749
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------