Provider Demographics
NPI:1861593006
Name:ROSE, MICHAEL R (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:100 E CALIFORNIA BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3205
Mailing Address - Country:US
Mailing Address - Phone:626-269-5371
Mailing Address - Fax:626-574-7188
Practice Address - Street 1:2400 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-2219
Practice Address - Country:US
Practice Address - Phone:323-221-6121
Practice Address - Fax:323-221-6120
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2014-01-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG33914207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0014310Medicaid
CAGR0014310Medicaid
CAGR0014310Medicaid