Provider Demographics
NPI:1053380634
Name:ROSE, RICHARD KT (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:KT
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9961 SIERRA AVE
Mailing Address - Street 2:MOB #3
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6720
Mailing Address - Country:US
Mailing Address - Phone:909-427-5611
Mailing Address - Fax:909-427-7086
Practice Address - Street 1:9961 SIERRA AVE
Practice Address - Street 2:MOB # 3
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:909-427-4549
Practice Address - Fax:909-427-7086
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
HIMD12937207X00000X, 207XS0114X, 207XX0005X, 207XX0801X
CAA71631207X00000X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIMD12937-01OtherQUEENSHEALTHCARE/MDX
HI247361OtherHMSA
HI084813001OtherDMERC
HI56682001Medicaid
HI56682001Medicaid