Provider Demographics
NPI:1982645131
Name:ROSE, JUDITH G (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:G
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 COTNER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3303
Mailing Address - Country:US
Mailing Address - Phone:310-445-2951
Mailing Address - Fax:310-479-1459
Practice Address - Street 1:1516 COTNER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3303
Practice Address - Country:US
Practice Address - Phone:310-445-2951
Practice Address - Fax:310-479-1459
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG362792085R0202X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G362790Medicaid
CAGR0106039Medicaid
CA00G362790OtherBLUE SHIELD
CA00G362790Medicare PIN
CAGR0106039Medicaid
CA00G362793Medicare PIN
CAWG36279PMedicare PIN
00G362792Medicare PIN
CA00G3627910Medicare PIN
CA00G362791Medicare PIN
CA00G362796Medicare PIN
CAWG36279CMedicare PIN
CAWG36279KMedicare PIN
CA00G362790OtherBLUE SHIELD
CAWG36279AMedicare PIN
CAA46629Medicare UPIN
CAWG36279QMedicare PIN
CAWG36279JMedicare PIN
CAWG36279MMedicare PIN
CAWG36279NMedicare PIN
CA00G362795Medicare PIN
CAAO719ZMedicare PIN