Provider Demographics
NPI:1982626719
Name:ROSE, OTTILIE T (MD)
Entity Type:Individual
Prefix:
First Name:OTTILIE
Middle Name:T
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 PERSHING DR
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1433
Mailing Address - Country:US
Mailing Address - Phone:203-709-8873
Mailing Address - Fax:203-709-8689
Practice Address - Street 1:78 PERSHING DR
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1433
Practice Address - Country:US
Practice Address - Phone:203-709-8873
Practice Address - Fax:203-709-8689
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030635208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001306358Medicaid
CTG39612Medicare UPIN
CT370001708Medicare PIN
CT370001607Medicare PIN