Provider Demographics
NPI:1639434475
Name:ROSA, JAIME SOU (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:SOU
Last Name:ROSA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 CAMPUS DR
Mailing Address - Street 2:CCSR 3215, MC 5366
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-5101
Mailing Address - Country:US
Mailing Address - Phone:650-498-6073
Mailing Address - Fax:650-498-5560
Practice Address - Street 1:269 CAMPUS DR
Practice Address - Street 2:CCSR 3215, MC 5366
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-5101
Practice Address - Country:US
Practice Address - Phone:650-498-6073
Practice Address - Fax:650-498-5560
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA 121193207K00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology