Provider Demographics
NPI:1982765574
Name:ROSE, MOSHE (MD)
Entity Type:Individual
Prefix:
First Name:MOSHE
Middle Name:
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 1:1 MAPLEWOOD TERR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701
Mailing Address - Country:US
Mailing Address - Phone:732-942-2988
Mailing Address - Fax:
Practice Address - Street 1:21 QUITMAN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-4105
Practice Address - Country:US
Practice Address - Phone:973-424-4329
Practice Address - Fax:973-824-0806
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA076161002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0097837Medicaid
NJ0097837Medicaid
NJ063701Medicare ID - Type UnspecifiedGROUP MEDICARE