Provider Demographics
NPI:1003892027
Name:ROSE, DOUGLAS J (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
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 1:1091 APONO PL
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2701
Mailing Address - Country:US
Mailing Address - Phone:423-341-5473
Mailing Address - Fax:888-960-2830
Practice Address - Street 1:45 MOHOULI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-7210
Practice Address - Country:US
Practice Address - Phone:808-932-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI18758207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G69541Medicare UPIN
TN3874522Medicare ID - Type Unspecified