1053339606 NPI number — DR. MELISSA ROSE MD

Table of content: DR. MELISSA ROSE MD (NPI 1053339606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053339606 NPI number — DR. MELISSA ROSE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSE
Provider First Name:
MELISSA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BONDER
Provider Other First Name:
MELISSA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1053339606
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11875 DUBLIN BLVD
Provider Second Line Business Mailing Address:
SUITE C140
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94568-2843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-587-2500
Provider Business Mailing Address Fax Number:
925-587-2511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3700 SUNSET LN
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
ANTIOCH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94509-6199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-755-8500
Provider Business Practice Location Address Fax Number:
925-755-8200
Provider Enumeration Date:
07/18/2006

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: 208000000X , with the licence number:  25MA07624600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: A112131 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 60011948 . This is a "HORIZON NJ HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 60011957 . This is a "HORIZON NJ HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7588624 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11341226 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9410411 . This is a "PHCS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 60011952 . This is a "HORIZON NJ HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 60011954 . This is a "HORIZON NJ HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3682036 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".




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