1831269984 NPI number — JONATHAN DANIEL ROSE DPM

Table of content: JONATHAN DANIEL ROSE DPM (NPI 1831269984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831269984 NPI number — JONATHAN DANIEL ROSE DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSE
Provider First Name:
JONATHAN
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831269984
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10845 PHILADELPHIA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE MARSH
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21162-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-335-0008
Provider Business Mailing Address Fax Number:
410-335-1133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2324 W JOPPA RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUTHERVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21093-4617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-583-5444
Provider Business Practice Location Address Fax Number:
443-583-5385
Provider Enumeration Date:
11/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  01344 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 510006200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: E602 . This is a "NATIONAL CAP BLUE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: H792 . This is a "BLUE CROSS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".