Provider Demographics
NPI:1699752386
Name:ROSE, DAVID MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7202 GLEN FOREST DR STE 200
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3780
Mailing Address - Country:US
Mailing Address - Phone:804-673-2024
Mailing Address - Fax:804-673-1796
Practice Address - Street 1:10710 MIDLOTHIAN TPKE STE 138
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235
Practice Address - Country:US
Practice Address - Phone:804-330-7990
Practice Address - Fax:804-660-2701
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012361959208600000X
VA0101-236195208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010064384Medicaid
G93562Medicare UPIN
VA010064384Medicaid