Provider Demographics
NPI:1497883326
Name:ROSE, JOHN CREIGHTON (PHD, MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CREIGHTON
Last Name:ROSE
Suffix:
Gender:M
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14030 NE 24TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-3731
Mailing Address - Country:US
Mailing Address - Phone:253-341-6178
Mailing Address - Fax:425-458-9631
Practice Address - Street 1:14030 NE 24TH ST STE 104
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3731
Practice Address - Country:US
Practice Address - Phone:253-341-6178
Practice Address - Fax:425-458-9631
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000317332084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8208282Medicaid
F74634Medicare UPIN