Provider Demographics
NPI:1972722932
Name:ROSE EYE MEDICAL
Entity type:Organization
Organization Name:ROSE EYE MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:G33914
Authorized Official - Phone:323-221-6121
Mailing Address - Street 1:3420 BRISTOL ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-7170
Mailing Address - Country:US
Mailing Address - Phone:714-272-7303
Mailing Address - Fax:
Practice Address - Street 1:3420 BRISTOL ST
Practice Address - Street 2:SUITE 700
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-7170
Practice Address - Country:US
Practice Address - Phone:714-957-0273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33914174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0014311Medicaid
CAW3411AMedicare ID - Type Unspecified