Provider Demographics
NPI:1710005038
Name:ROSE, DAVID S (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:S
Last Name:ROSE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 FIDLER LN
Mailing Address - Street 2:SUITE 1417
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3425
Mailing Address - Country:US
Mailing Address - Phone:301-587-5735
Mailing Address - Fax:240-331-7190
Practice Address - Street 1:1110 FIDLER LN
Practice Address - Street 2:SUITE 1417
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3425
Practice Address - Country:US
Practice Address - Phone:301-587-5735
Practice Address - Fax:240-331-7190
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2429103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD720-260Medicare UPIN