Provider Demographics
NPI:1629078415
Name:HENDRIX, ROSE MARIE (DO)
Entity Type:Individual
Prefix:MS
First Name:ROSE MARIE
Middle Name:
Last Name:HENDRIX
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 EMELINE AVE
Mailing Address - Street 2:ATTN: CLINIC ADMIN
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1966
Mailing Address - Country:US
Mailing Address - Phone:831-454-4100
Mailing Address - Fax:831-454-4296
Practice Address - Street 1:1080 EMELINE AVE
Practice Address - Street 2:ATTN: CLINIC ADMIN
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1966
Practice Address - Country:US
Practice Address - Phone:831-454-4100
Practice Address - Fax:831-454-4296
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 8020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BH6133855OtherDEA
CA020A80200Medicare ID - Type Unspecified
G78485Medicare UPIN