Basic Information
Provider Information | |||||||||
NPI: | 1881968733 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSE | ||||||||
FirstName: | AVA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROSENBLUM | ||||||||
OtherFirstName: | DAVID | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 617 | ||||||||
Address2: |   | ||||||||
City: | SOMERTON | ||||||||
State: | AZ | ||||||||
PostalCode: | 853500617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9283157910 | ||||||||
FaxNumber: | 9287226113 | ||||||||
Practice Location | |||||||||
Address1: | 151 S OAK AVE STE 2 | ||||||||
Address2: |   | ||||||||
City: | SAN LUIS | ||||||||
State: | AZ | ||||||||
PostalCode: | 853360756 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9286620414 | ||||||||
FaxNumber: | 9287226113 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2012 | ||||||||
LastUpdateDate: | 05/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 50321 | AZ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.