Provider Demographics
NPI:1114035748
Name:ROSE, ROBERT J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28780
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99228-8780
Mailing Address - Country:US
Mailing Address - Phone:509-484-6000
Mailing Address - Fax:
Practice Address - Street 1:9405 N NEWPORT HWY
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1242
Practice Address - Country:US
Practice Address - Phone:509-484-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017397207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1331206Medicaid
WA000301359Medicare ID - Type Unspecified
WAA07368Medicare UPIN