Provider Demographics
NPI:1801212428
Name:ROSE, MARK THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:ROSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4760 BELPAR ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3603
Mailing Address - Country:US
Mailing Address - Phone:330-492-9200
Mailing Address - Fax:330-492-5454
Practice Address - Street 1:4760 BELPAR ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3603
Practice Address - Country:US
Practice Address - Phone:330-492-9200
Practice Address - Fax:330-492-5454
Is Sole Proprietor?:No
Enumeration Date:2014-03-06
Last Update Date:2023-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0102205481207X00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1801212428Medicaid