Provider Demographics
NPI:1790704518
Name:ROSE, K DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:K DANIEL
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 W SODA ROCK LN
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-9631
Mailing Address - Country:US
Mailing Address - Phone:707-433-5667
Mailing Address - Fax:707-473-4405
Practice Address - Street 1:4050 W SODA ROCK LN
Practice Address - Street 2:
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-9631
Practice Address - Country:US
Practice Address - Phone:707-433-5667
Practice Address - Fax:707-473-4405
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG25578OtherMEDICAL LICENSE
CA00G255780Medicaid
CA00G255780Medicaid