Provider Demographics
NPI:1013955327
Name:ROSE, JAMES J JR (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:J
Last Name:ROSE
Suffix:JR
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 1:325 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-2060
Mailing Address - Country:US
Mailing Address - Phone:801-798-7301
Mailing Address - Fax:801-798-8513
Practice Address - Street 1:325 W CENTER ST
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-2060
Practice Address - Country:US
Practice Address - Phone:801-798-7301
Practice Address - Fax:801-798-8513
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT159123-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT05315Medicaid
UT05315Medicaid