Provider Demographics
NPI:1073544250
Name:ROSE, SUSAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1725 E 19TH ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5472
Mailing Address - Country:US
Mailing Address - Phone:918-301-2505
Mailing Address - Fax:918-301-3633
Practice Address - Street 1:1725 E 19TH ST
Practice Address - Street 2:SUITE 800
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5472
Practice Address - Country:US
Practice Address - Phone:918-301-2505
Practice Address - Fax:918-301-3633
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK14809208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100162600AMedicaid
OK020047731OtherRAILROAD MEDICARE
OK$$$$$$$$$003OtherBLUE CROSS BLUE SHIELD
OK100162600AMedicaid
OK020047731OtherRAILROAD MEDICARE