Provider Demographics
NPI:1548323355
Name:ROSE, CAROLYN JOAN (MD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JOAN
Last Name:ROSE
Suffix:
Gender:F
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:PO BOX 155
Mailing Address - Street 2:5300 HIGHWAY 49 NORTH
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-0155
Mailing Address - Country:US
Mailing Address - Phone:209-966-3672
Mailing Address - Fax:209-966-5548
Practice Address - Street 1:5300 HIGHWAY 49 NORTH
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-0155
Practice Address - Country:US
Practice Address - Phone:209-966-3672
Practice Address - Fax:209-966-5548
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 41263207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA 41263OtherMEDICAL LICENSE
CA00A412630Medicaid
CA00A412630Medicare PIN
CA00A412630Medicaid