Provider Demographics
NPI:1336131085
Name:ROSE, ROBERTA F (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:F
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:761 MAIN AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-1080
Mailing Address - Country:US
Mailing Address - Phone:203-852-2290
Mailing Address - Fax:203-899-5029
Practice Address - Street 1:40 CROSS ST
Practice Address - Street 2:4TH FL
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-4647
Practice Address - Country:US
Practice Address - Phone:203-845-4800
Practice Address - Fax:203-845-4871
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034575207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001345752Medicaid
CT1336131085Medicare PIN
CT001345752Medicaid