Provider Demographics
NPI:1912947086
Name:ROSE, JOHN W (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:ROSE
Suffix:
Gender:M
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:PO BOX 413027
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3027
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-585-6387
Practice Address - Fax:801-584-5654
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT173744-12052084P0804X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry