Provider Demographics
NPI:1184615734
Name:ROSE, ROGER P (DO)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:P
Last Name:ROSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10440 E RIGGS RD STE 203
Mailing Address - Street 2:
Mailing Address - City:SUN LAKES
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-7755
Mailing Address - Country:US
Mailing Address - Phone:480-378-2253
Mailing Address - Fax:480-378-3658
Practice Address - Street 1:10440 E RIGGS RD STE 203
Practice Address - Street 2:
Practice Address - City:SUN LAKES
Practice Address - State:AZ
Practice Address - Zip Code:85248-7755
Practice Address - Country:US
Practice Address - Phone:480-378-2253
Practice Address - Fax:480-378-3658
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ2939207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ65319OtherMEDICARE PROVIDER NUMBER
AZG17527Medicare UPIN