Provider Demographics
NPI:1205817137
Name:ROSE, FREDERIC (OD)
Entity Type:Individual
Prefix:DR
First Name:FREDERIC
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 MERRIMACK ST
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01830-6207
Mailing Address - Country:US
Mailing Address - Phone:978-374-0386
Mailing Address - Fax:978-372-3631
Practice Address - Street 1:72 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-6207
Practice Address - Country:US
Practice Address - Phone:978-374-0386
Practice Address - Fax:978-372-3631
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA2139152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2200374OtherUNITED HEALTH
507326OtherAETNA
MA0392360001OtherMEDICARE OTHER
151464OtherHARV PILGRIM
MA705074OtherTUFTS
MA0396516Medicaid
MAW15354OtherBCBS
MA0392360001OtherMEDICARE OTHER
048358Medicare ID - Type Unspecified
0392360001Medicare NSC