Provider Demographics
NPI:1215357991
Name:ROSE, MIRANDA ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ELIZABETH
Last Name:ROSE
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 1:545 METRO PL S STE 100
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-5353
Mailing Address - Country:US
Mailing Address - Phone:415-671-2165
Mailing Address - Fax:
Practice Address - Street 1:545 METRO PL S STE 100
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-5353
Practice Address - Country:US
Practice Address - Phone:415-671-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35129488207Q00000X
WV30017207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H609640OtherMEDICARE