Provider Demographics
NPI:1780697482
Name:ROSE, DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:R.
Other - Middle Name:DAVID
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1600 CRAIN HWY S
Mailing Address - Street 2:STE 207
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5577
Mailing Address - Country:US
Mailing Address - Phone:410-760-5400
Mailing Address - Fax:410-760-5488
Practice Address - Street 1:1600 CRAIN HWY S
Practice Address - Street 2:STE 207
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5577
Practice Address - Country:US
Practice Address - Phone:410-760-5400
Practice Address - Fax:410-760-5488
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD19991207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E13678Medicare UPIN
7041DMedicare ID - Type Unspecified
MD472021100Medicaid