Provider Demographics
NPI:1285668962
Name:ROSE, DANIEL M (MD)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:M
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12134 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3205
Mailing Address - Country:US
Mailing Address - Phone:818-762-8702
Mailing Address - Fax:818-761-2583
Practice Address - Street 1:12134 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3205
Practice Address - Country:US
Practice Address - Phone:818-762-8702
Practice Address - Fax:818-761-2583
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44506207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE94041Medicare UPIN