Basic Information
| Provider Information | |||||||||
| NPI: | 1639434475 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSA | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | SOU | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 269 CAMPUS DR | ||||||||
| Address2: | CCSR 3215, MC 5366 | ||||||||
| City: | STANFORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943055101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504986073 | ||||||||
| FaxNumber: | 6504985560 | ||||||||
| Practice Location | |||||||||
| Address1: | 269 CAMPUS DR | ||||||||
| Address2: | CCSR 3215, MC 5366 | ||||||||
| City: | STANFORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943055101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504986073 | ||||||||
| FaxNumber: | 6504985560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2012 | ||||||||
| LastUpdateDate: | 11/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | A 121193 | CA | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | 208000000X | A 121193 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.