Provider Demographics
NPI:1285668962
Name:ROSE, DANIEL M (MD)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:M
Last Name:ROSE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OFFICE MANAGER/MA
Mailing Address - Street 1:14435 HAMLIN ST
Mailing Address - Street 2:SUITE #104
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-6205
Mailing Address - Country:US
Mailing Address - Phone:714-345-8427
Mailing Address - Fax:818-855-1254
Practice Address - Street 1:14435 HAMLIN ST
Practice Address - Street 2:SUITE #104
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-6205
Practice Address - Country:US
Practice Address - Phone:714-345-8427
Practice Address - Fax:818-855-1254
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44506207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE94041Medicare UPIN