Provider Demographics
NPI:1881663342
Name:ROSE, REENU SARA EAPEN
Entity Type:Individual
Prefix:MRS
First Name:REENU
Middle Name:SARA EAPEN
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:REENU
Other - Middle Name:SARA
Other - Last Name:EAPEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 192647
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-8524
Mailing Address - Country:US
Mailing Address - Phone:214-824-9600
Mailing Address - Fax:214-824-9601
Practice Address - Street 1:411 N. WASHINGTON AVE.
Practice Address - Street 2:SUITE 3300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1774
Practice Address - Country:US
Practice Address - Phone:214-824-9600
Practice Address - Fax:214-824-9601
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL01482080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149789307Medicaid
TX8L16162OtherMEDICARE ID -INDIVIDUAL