Provider Demographics
NPI:1538352810
Name:ROSE, MARY HODGSON (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:HODGSON
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:HODGSON
Other - Last Name:WERTHEIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5477 CAMPBELL LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221
Mailing Address - Country:US
Mailing Address - Phone:360-293-2176
Mailing Address - Fax:
Practice Address - Street 1:5477 CAMPBELL LAKE ROAD
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221
Practice Address - Country:US
Practice Address - Phone:360-293-2176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAWA1018514Medicaid
A06167Medicare UPIN