Provider Demographics
NPI:1174505978
Name:ROSE, DONALD DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:DAVID
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 1:521 LAKE CHRISTINE DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5101
Mailing Address - Country:US
Mailing Address - Phone:618-277-9168
Mailing Address - Fax:
Practice Address - Street 1:521 LAKE CHRISTINE DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5101
Practice Address - Country:US
Practice Address - Phone:618-277-9168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057334207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057334Medicaid
IL036057334Medicaid
IL647450Medicare PIN