Basic Information
Provider Information | |||||||||
NPI: | 1043271521 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROBERT J. ROSE, MD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MARIPOSA FAMILY MEDICINE ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 155 | ||||||||
Address2: |   | ||||||||
City: | MARIPOSA | ||||||||
State: | CA | ||||||||
PostalCode: | 953380155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2099663672 | ||||||||
FaxNumber: | 2099665548 | ||||||||
Practice Location | |||||||||
Address1: | 5300 HWY 49N | ||||||||
Address2: |   | ||||||||
City: | MARIPOSA | ||||||||
State: | CA | ||||||||
PostalCode: | 95338 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2099663672 | ||||||||
FaxNumber: | 2099665548 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2006 | ||||||||
LastUpdateDate: | 04/01/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROSE | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2099663672 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | ZZZ01691Z | 01 | CA | BLUE SHIELD PIN | OTHER | RHM53871F | 05 | CA |   | MEDICAID |