Provider Demographics
NPI:1851199863
Name:ROSE, DEREK J
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:J
Last Name:ROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3745 OVERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-6311
Mailing Address - Country:US
Mailing Address - Phone:310-392-5855
Mailing Address - Fax:
Practice Address - Street 1:3745 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-6311
Practice Address - Country:US
Practice Address - Phone:310-392-5855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-05
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X, 373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No172V00000XOther Service ProvidersCommunity Health Worker