Provider Demographics
NPI:1114009461
Name:ROSEN, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:ROSEN
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 1:2020 PALOMINO LN STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4892
Mailing Address - Country:US
Mailing Address - Phone:702-474-7200
Mailing Address - Fax:702-474-0009
Practice Address - Street 1:2020 PALOMINO LN STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4892
Practice Address - Country:US
Practice Address - Phone:702-474-7200
Practice Address - Fax:702-474-0009
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6850207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2019424Medicaid
E46799Medicare UPIN
NV2019424Medicaid