Provider Demographics
NPI:1285654418
Name:ROSE, DOUGLAS G (OD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:G
Last Name:ROSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:390 MID RIVERS MALL DR
Practice Address - Street 2:SUITE 290
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1565
Practice Address - Country:US
Practice Address - Phone:636-279-2020
Practice Address - Fax:636-279-1055
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002016606152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1285654418Medicaid
MO0640380017Medicare PIN
MO1285654418Medicaid
MOMA5227029Medicare UPIN
MOU91223Medicare UPIN