Provider Demographics
NPI:1275724056
Name:ROSE, AMY E (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:E
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 1:401 E 74TH ST APT 5RS
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-3919
Mailing Address - Country:US
Mailing Address - Phone:917-414-1373
Mailing Address - Fax:
Practice Address - Street 1:31 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREENVALE
Practice Address - State:NY
Practice Address - Zip Code:11548-1320
Practice Address - Country:US
Practice Address - Phone:516-484-9000
Practice Address - Fax:516-484-7549
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY247173207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program