Provider Demographics
NPI:1508020645
Name:ROSE, SHANA WIDICK (MD)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:WIDICK
Last Name:ROSE
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Gender:F
Credentials:MD
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Mailing Address - Street 1:1011 BOWLES AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2395
Mailing Address - Country:US
Mailing Address - Phone:636-717-1700
Mailing Address - Fax:636-203-4727
Practice Address - Street 1:1011 BOWLES AVE
Practice Address - Street 2:SUITE 415
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2395
Practice Address - Country:US
Practice Address - Phone:636-717-1700
Practice Address - Fax:636-203-4727
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2015-01-23
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Provider Licenses
StateLicense IDTaxonomies
MO2011014018207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology