Provider Demographics
NPI:1275101701
Name:ROSE, EVAN JAMES (DO)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:JAMES
Last Name:ROSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7567 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1460
Mailing Address - Country:US
Mailing Address - Phone:314-412-6924
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 3019B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8267
Practice Address - Country:US
Practice Address - Phone:314-509-5305
Practice Address - Fax:314-251-4454
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021021663207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty