Provider Demographics
NPI:1336338185
Name:ROSE, DAVID CLARENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CLARENCE
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 1:6192 DEVON DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3821
Mailing Address - Country:US
Mailing Address - Phone:443-528-2874
Mailing Address - Fax:
Practice Address - Street 1:6192 DEVON DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3821
Practice Address - Country:US
Practice Address - Phone:443-528-2874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05852400208000000X
MDD0046839208000000X
DCMD30077208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC034538700Medicaid
NJ8751404Medicaid
NJ0133469Medicaid
NJ0133469Medicaid
NJ063701Medicare PIN