Provider Demographics
NPI:1699703611
Name:ROSE, LINDA (MD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 RIVERGATE UNIT 212
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7488
Mailing Address - Country:US
Mailing Address - Phone:970-259-2202
Mailing Address - Fax:
Practice Address - Street 1:575 RIVERGATE UNIT 212
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301
Practice Address - Country:US
Practice Address - Phone:970-259-2202
Practice Address - Fax:970-259-2837
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD63330207W00000X
NMMD2007-0035207W00000X
CODR0061431207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD408203600Medicaid
MDM082Medicare ID - Type Unspecified
MDKR86JHMedicare ID - Type Unspecified