Provider Demographics
NPI:1386389534
Name:ROSE, KOLLEEN DAWN (OD)
Entity type:Individual
Prefix:
First Name:KOLLEEN
Middle Name:DAWN
Last Name:ROSE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-5568
Mailing Address - Country:US
Mailing Address - Phone:540-953-2020
Mailing Address - Fax:
Practice Address - Street 1:1440 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-5568
Practice Address - Country:US
Practice Address - Phone:540-953-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618003402152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8740738OtherUNITED HEALTHCARE