Provider Demographics
NPI:1518025089
Name:ROSE, TRICIA D (OD)
Entity Type:Individual
Prefix:DR
First Name:TRICIA
Middle Name:D
Last Name:ROSE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 HARRISON ST
Mailing Address - Street 2:SUITE 218
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3056
Mailing Address - Country:US
Mailing Address - Phone:315-295-0467
Mailing Address - Fax:315-295-1096
Practice Address - Street 1:224 HARRISON ST
Practice Address - Street 2:SUITE 218
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3056
Practice Address - Country:US
Practice Address - Phone:315-295-0467
Practice Address - Fax:315-295-1096
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006002152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02362605Medicaid
NY5458840001Medicare NSC
NY02362605Medicaid