Provider Demographics
NPI:1851364723
Name:ROSE, BRIAN THOMAS (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:THOMAS
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 1:243 E 6100 S
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7302
Mailing Address - Country:US
Mailing Address - Phone:801-585-3927
Mailing Address - Fax:801-262-3069
Practice Address - Street 1:243 E 6100 S
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7302
Practice Address - Country:US
Practice Address - Phone:801-585-3927
Practice Address - Fax:801-262-3069
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20810207W00000X
UT12404247-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF30554Medicare UPIN