Provider Demographics
NPI:1861037269
Name:ROSE, SHIVAZ (DPT)
Entity Type:Individual
Prefix:DR
First Name:SHIVAZ
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:153 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4405
Practice Address - Country:US
Practice Address - Phone:201-819-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-10
Last Update Date:2019-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist