Provider Demographics
NPI:1396775912
Name:ROSE, JEFFREY PAUL (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PAUL
Last Name:ROSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20929 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2410
Mailing Address - Country:US
Mailing Address - Phone:718-279-3713
Mailing Address - Fax:718-279-4230
Practice Address - Street 1:20929 28TH AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-2410
Practice Address - Country:US
Practice Address - Phone:718-279-3713
Practice Address - Fax:718-279-4230
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003202-1152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management