Provider Demographics
NPI:1184623001
Name:ROSE, JODY GENE (DPM)
Entity type:Individual
Prefix:DR
First Name:JODY
Middle Name:GENE
Last Name:ROSE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 GRANT BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-0038
Mailing Address - Country:US
Mailing Address - Phone:405-733-1711
Mailing Address - Fax:405-733-3111
Practice Address - Street 1:4400 GRANT BLVD STE 110
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-0038
Practice Address - Country:US
Practice Address - Phone:405-733-1711
Practice Address - Fax:405-733-3111
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK204213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200522012OtherMEDICARE GROUP
OKP00010135OtherRAILROAD MEDICARE
OKU88423Medicare UPIN
OK249634501Medicare PIN
OK0796900001Medicare NSC
OKP00010135OtherRAILROAD MEDICARE