Provider Demographics
NPI:1497804843
Name:ROSE, JONATHAN DOUGLAS (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DOUGLAS
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 HAMPTON DR
Mailing Address - Street 2:UNIT A301
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2790
Mailing Address - Country:US
Mailing Address - Phone:310-717-1494
Mailing Address - Fax:
Practice Address - Street 1:615 HAMPTON DR
Practice Address - Street 2:UNIT A301
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2790
Practice Address - Country:US
Practice Address - Phone:310-717-1494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY242646-1207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology