Basic Information
| Provider Information | |||||||||
| NPI: | 1851351951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367650020 | ||||||||
| FaxNumber: | 3367650581 | ||||||||
| Practice Location | |||||||||
| Address1: | 755 HIGHLAND OAKS DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271037106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367650020 | ||||||||
| FaxNumber: | 3367650581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 9600712 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 891068H | 05 | NC | MEDICAID | 1851351951 | 05 | VA | MEDICAID |