Provider Demographics
NPI:1285864843
Name:ROSE, MIKO (DO)
Entity Type:Individual
Prefix:
First Name:MIKO
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5303S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-3800
Mailing Address - Country:US
Mailing Address - Phone:517-244-8060
Mailing Address - Fax:517-244-7180
Practice Address - Street 1:A233 EAST FEE HALL
Practice Address - Street 2:GEN ADULT PSYCHIATRY RESIDENCY MSU
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-1316
Practice Address - Country:US
Practice Address - Phone:517-432-2993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010191682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1285864843Medicaid
MI1285864843Medicaid