Provider Demographics
NPI:1881968733
Name:ROSE, AVA (MD)
Entity type:Individual
Prefix:MS
First Name:AVA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:ROSENBLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-0617
Mailing Address - Country:US
Mailing Address - Phone:928-315-7910
Mailing Address - Fax:928-722-6113
Practice Address - Street 1:151 S OAK AVE STE 2
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85336-0756
Practice Address - Country:US
Practice Address - Phone:928-662-0414
Practice Address - Fax:928-722-6113
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ50321207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine