Provider Demographics
NPI:1356387641
Name:ROSE, JOHN H (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:ROSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 AVENUE N
Mailing Address - Street 2:
Mailing Address - City:HASKELL
Mailing Address - State:TX
Mailing Address - Zip Code:79521-5415
Mailing Address - Country:US
Mailing Address - Phone:940-889-5583
Mailing Address - Fax:940-889-8835
Practice Address - Street 1:201 STADIUM DRIVE
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:TX
Practice Address - Zip Code:76380
Practice Address - Country:US
Practice Address - Phone:940-889-5583
Practice Address - Fax:940-889-8835
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9564207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0026MPOtherBLUE CROSS
TX077617102OtherADD TPI
TX077617103Medicaid
TX077617103Medicaid
TX00U49TMedicare PIN