Provider Demographics
NPI:1811392715
Name:ROSE, DAVID LAYNE (IDC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LAYNE
Last Name:ROSE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2531 RIDGE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-4853
Mailing Address - Country:US
Mailing Address - Phone:269-503-0912
Mailing Address - Fax:
Practice Address - Street 1:2531 RIDGE VIEW DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-4853
Practice Address - Country:US
Practice Address - Phone:269-503-0912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman