Provider Demographics
NPI:1982615969
Name:ROSE, NORMAN A (OD)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:A
Last Name:ROSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 BRIARWOOD PL
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-4005
Mailing Address - Country:US
Mailing Address - Phone:760-746-0570
Mailing Address - Fax:760-746-0570
Practice Address - Street 1:41593 WINCHESTER RD STE 200
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-4857
Practice Address - Country:US
Practice Address - Phone:760-746-0570
Practice Address - Fax:760-746-0570
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA7630TLG152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5999224Medicaid
CAOP7630Medicare ID - Type Unspecified
CAU19446Medicare UPIN