Provider Demographics
NPI:1790775922
Name:ROSE, RICHARD ANTHONY (DPM)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ANTHONY
Last Name:ROSE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1687
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-0029
Mailing Address - Country:US
Mailing Address - Phone:641-472-9371
Mailing Address - Fax:641-472-9589
Practice Address - Street 1:202 E BRIGGS AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556-2925
Practice Address - Country:US
Practice Address - Phone:641-472-9731
Practice Address - Fax:641-472-9589
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA688213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8970OtherMIDLAND'S CHOICE
IA0151696Medicaid
IA58773OtherBC / BS
421522093OtherEIN
IA58773OtherBC / BS
421522093OtherEIN