Provider Demographics
NPI:1629085873
Name:ROSE, ROBERT J (MD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:J
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:PO BOX 3768
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-3768
Mailing Address - Country:US
Mailing Address - Phone:209-725-7149
Mailing Address - Fax:209-726-0134
Practice Address - Street 1:5300 HIGHWAY 49 NORTH
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-1569
Practice Address - Country:US
Practice Address - Phone:209-966-3672
Practice Address - Fax:209-966-5548
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG52454207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G524540Medicaid
CARHM53871FMedicaid
CA00G524540Medicaid
TN553871Medicare Oscar/Certification
CARHM53871FMedicaid