Provider Demographics
NPI:1902863079
Name:ROSE, LESLIE W III (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:W
Last Name:ROSE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7605 FOREST AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-4938
Mailing Address - Country:US
Mailing Address - Phone:804-288-8338
Mailing Address - Fax:804-282-2424
Practice Address - Street 1:7605 FOREST AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-4938
Practice Address - Country:US
Practice Address - Phone:804-288-8338
Practice Address - Fax:804-282-2424
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101032142207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6040951Medicaid
VA110002057Medicare ID - Type Unspecified
VA6040951Medicaid