Provider Demographics
NPI:1831290485
Name:ROSE, DOUGLAS R (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 SW 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66604-1301
Mailing Address - Country:US
Mailing Address - Phone:785-354-6000
Mailing Address - Fax:785-354-5004
Practice Address - Street 1:1500 SW 10TH AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-1301
Practice Address - Country:US
Practice Address - Phone:785-354-6000
Practice Address - Fax:785-354-5004
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-25144207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
613230OtherFIRSTGUARD HEALTH PLAN
046953OtherBLUE CROSS BLUE SHIELD KS
KS100164820BMedicaid
046953OtherBLUE CROSS BLUE SHIELD KS
613230OtherFIRSTGUARD HEALTH PLAN
KS100164820BMedicaid