Provider Demographics
NPI:1578717658
Name:ROSE, STACEY RUBIN (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:RUBIN
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ELAINE
Other - Last Name:RUBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6620 MAIN ST STE 1100D
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2348
Mailing Address - Country:US
Mailing Address - Phone:713-798-5588
Mailing Address - Fax:
Practice Address - Street 1:6620 MAIN ST STE 1100D
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2348
Practice Address - Country:US
Practice Address - Phone:713-798-5588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-16
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4047207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB114182Medicare PIN