Provider Demographics
NPI:1073642658
Name:ROSENSTEIN, MYRA (MD)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:ROSENSTEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MYRA
Other - Middle Name:
Other - Last Name:ROSENSTEIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:65 KANE ST
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-2110
Practice Address - Country:US
Practice Address - Phone:860-523-6436
Practice Address - Fax:860-523-3775
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT24331207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1073642658Medicaid
CTD400001259Medicare PIN