Provider Demographics
NPI:1326002973
Name:ROSE, ALLYN PATRICK (MD)
Entity type:Individual
Prefix:
First Name:ALLYN
Middle Name:PATRICK
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:A
Other - Middle Name:PATRICK
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5495 S 500 E
Mailing Address - Street 2:STE 330
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405
Mailing Address - Country:US
Mailing Address - Phone:801-476-2717
Mailing Address - Fax:801-476-7183
Practice Address - Street 1:5495 S 500 E
Practice Address - Street 2:STE 330
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405
Practice Address - Country:US
Practice Address - Phone:801-476-2717
Practice Address - Fax:801-476-7183
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1649101205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D76030Medicare UPIN