Provider Demographics
NPI:1831269984
Name:ROSE, JONATHAN DANIEL (DPM)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DANIEL
Last Name:ROSE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10845 PHILADELPHIA RD
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-1717
Mailing Address - Country:US
Mailing Address - Phone:410-335-0008
Mailing Address - Fax:410-335-1133
Practice Address - Street 1:2324 W JOPPA RD STE 100
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4617
Practice Address - Country:US
Practice Address - Phone:443-583-5444
Practice Address - Fax:443-583-5385
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01344213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD510006200Medicaid
MDE602OtherNATIONAL CAP BLUE
MDH792OtherBLUE CROSS
U90119Medicare UPIN