Provider Demographics
NPI:1205854080
Name:ROISE, DOUGLAS A (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:ROISE
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 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:701-364-8906
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4957207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND142059OtherUCARE #
ND14544Medicaid
ND12352OtherSIOUX VALLEY #
ND88D16ROOtherFGO MNBS#
NDHP38337OtherHEALTHPARTNERS #
ND1100119OtherFGO MEDICA #
ND17475Medicaid
ND1012767OtherARAZ #
ND19107OtherFGO NDBS #
NDDA9011026994OtherPREF 1 #
ND1100125OtherINN MEDICA #
ND213627900Medicaid
NDDA9011026994OtherPREF 1 #
ND88D16ROOtherFGO MNBS#
ND19107Medicare ID - Type UnspecifiedFGO NDMD #
ND713205Medicare PIN