Provider Demographics
NPI:1770812943
Name:ROSE, MIRIAM SHARON (MD)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:SHARON
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 SW 110TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3017
Mailing Address - Country:US
Mailing Address - Phone:503-819-1215
Mailing Address - Fax:
Practice Address - Street 1:4060 SW 110TH AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3017
Practice Address - Country:US
Practice Address - Phone:503-819-1215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-16
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27475208D00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice