Provider Demographics
NPI:1497778112
Name:ROSE, JAMES GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GARY
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:130 FISHER RD
Mailing Address - Street 2:SUITE 3-1
Mailing Address - City:BERLIN
Mailing Address - State:VT
Mailing Address - Zip Code:05602-9516
Mailing Address - Country:US
Mailing Address - Phone:802-225-7025
Mailing Address - Fax:802-225-7104
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:SUITE 3-1
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-225-7025
Practice Address - Fax:802-225-7104
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT042-0010379207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008758Medicaid
UT042-0010379OtherLICENCE
VT1008758Medicaid
A52651Medicare UPIN