Provider Demographics
NPI:1619992823
Name:ROSE, DONALD EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:EDWARD
Last Name:ROSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 MEADOW WOOD CT
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-7529
Mailing Address - Country:US
Mailing Address - Phone:916-933-8804
Mailing Address - Fax:
Practice Address - Street 1:199 E WEBSTER ST
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-2954
Practice Address - Country:US
Practice Address - Phone:530-458-3283
Practice Address - Fax:530-458-3215
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6476207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX64760Medicaid
CA020A64762Medicare PIN
CAF34573Medicare UPIN