Provider Demographics
NPI:1235299116
Name:ROSE, DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
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 1:224 TAYLOR MILLS RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-3281
Mailing Address - Country:US
Mailing Address - Phone:732-409-0128
Mailing Address - Fax:732-409-1131
Practice Address - Street 1:224 TAYLOR MILLS RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-3281
Practice Address - Country:US
Practice Address - Phone:732-409-0128
Practice Address - Fax:732-409-1131
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA040578002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC54855Medicare UPIN
NJRO447712Medicare PIN