Provider Demographics
NPI:1912780255
Name:ROSE, LARRY DON
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:DON
Last Name:ROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DALLAS
Other - Middle Name:
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1320 N ROCKWELL AVE APT B
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-3355
Mailing Address - Country:US
Mailing Address - Phone:405-210-4996
Mailing Address - Fax:
Practice Address - Street 1:2701 NW 39TH EXPY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3775
Practice Address - Country:US
Practice Address - Phone:866-848-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist