Provider Demographics
NPI:1851315063
Name:ROSE, MARC DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:DAVID
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 1:2020 CAMINO DEL RIO NORTH
Mailing Address - Street 2:SUITE 808
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108
Mailing Address - Country:US
Mailing Address - Phone:619-523-4969
Mailing Address - Fax:619-523-4943
Practice Address - Street 1:2020 CAMINO DEL RIO N
Practice Address - Street 2:SUITE 808
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1541
Practice Address - Country:US
Practice Address - Phone:619-523-4969
Practice Address - Fax:619-523-4943
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84123174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG84123OtherMEDICAL LICENSE
CAG84123OtherMEDICAL LICENSE
CAG84123Medicare ID - Type Unspecified