Provider Demographics
NPI:1205862356
Name:FOCKEN, ROSALIE R (MD)
Entity Type:Individual
Prefix:
First Name:ROSALIE
Middle Name:R
Last Name:FOCKEN
Suffix:
Gender:F
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 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9102
Practice Address - Street 1:14700 W SAINT TERESA ST STE 300
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67235-9630
Practice Address - Country:US
Practice Address - Phone:316-274-0142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS25432207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
059201OtherMEDICARE
KS100280210AMedicaid
KS100280210AMedicaid
KS100984OtherHPK
KS16970OtherCOVENTRY
G25170Medicare UPIN
KS100280210AMedicaid