Provider Demographics
NPI:1427055102
Name:ROSE, MARK RICHARD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:2801 FRANCISCAN DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2544
Practice Address - Country:US
Practice Address - Phone:979-776-5967
Practice Address - Fax:979-731-5619
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ8112207RC0200X, 208M00000X
CAA48234207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G11263Medicare UPIN