Provider Demographics
NPI:1083642342
Name:ROSE, DEMIAN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:DEMIAN
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3059 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94123-4009
Mailing Address - Country:US
Mailing Address - Phone:415-378-4888
Mailing Address - Fax:
Practice Address - Street 1:3059 FILLMORE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-4009
Practice Address - Country:US
Practice Address - Phone:415-378-4888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA846812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A846811Medicare ID - Type Unspecified
CA107517Medicare UPIN