Provider Demographics
NPI:1174550784
Name:ROSE, NICHOLAS ELIAS (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ELIAS
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 1:360 SAN MIGUEL DR
Mailing Address - Street 2:SUITE#701
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7853
Mailing Address - Country:US
Mailing Address - Phone:949-759-3600
Mailing Address - Fax:949-759-0282
Practice Address - Street 1:360 SAN MIGUEL DR
Practice Address - Street 2:SUITE#701
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7853
Practice Address - Country:US
Practice Address - Phone:949-759-3600
Practice Address - Fax:949-759-0282
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74766207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG74766Medicare ID - Type Unspecified
CAG47743Medicare UPIN