Provider Demographics
NPI:1952309569
Name:ROSE, CHRISTOPHER M (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:M
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:PO BOX 513969
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-3969
Mailing Address - Country:US
Mailing Address - Phone:310-335-4065
Mailing Address - Fax:310-335-4098
Practice Address - Street 1:181 S BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4504
Practice Address - Country:US
Practice Address - Phone:818-847-3440
Practice Address - Fax:818-847-3499
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49966174400000X
CAC431112085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G499660Medicaid
CO920007065OtherRR MEDICARE - CO
CO59186232Medicaid
CA300080912OtherRR MEDICARE
CA920006960OtherRR MEDICARE
INWG49966AMedicare PIN
CAFW623Medicare PIN
CA300080912OtherRR MEDICARE
CO920007065OtherRR MEDICARE - CO
CA00G499660Medicaid
CAWG49966CMedicare PIN
CO451058Medicare PIN
B57906Medicare UPIN
CO59186232Medicaid
CAWG49966FMedicare PIN