Provider Demographics
NPI:1982732319
Name:ROSE, CRAIG A (OD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
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 1:30234 LAUREL PL
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MO
Mailing Address - Zip Code:63552-3803
Mailing Address - Country:US
Mailing Address - Phone:660-385-4182
Mailing Address - Fax:
Practice Address - Street 1:1705 PROSPECT DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-2602
Practice Address - Country:US
Practice Address - Phone:660-385-5724
Practice Address - Fax:660-385-3924
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03114152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO250705OtherHEALTHLINK
MO250705OtherHEALTHLINK