Provider Demographics
NPI:1265727457
Name:ROSE, COURTNEY E (DO)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:E
Last Name:ROSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:203 NACOGDOCHES ST
Mailing Address - Street 2:SUITE 275
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-2462
Mailing Address - Country:US
Mailing Address - Phone:309-541-5472
Mailing Address - Fax:903-541-5470
Practice Address - Street 1:203 NACOGDOCHES ST
Practice Address - Street 2:SUITE 275
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-2462
Practice Address - Country:US
Practice Address - Phone:309-541-5472
Practice Address - Fax:903-541-5470
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9947208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics