Provider Demographics
NPI:1114900925
Name:ROSEN, BONNIE SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:SUE
Last Name:ROSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SCENIC VIEW CT EAST
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746
Mailing Address - Country:US
Mailing Address - Phone:516-901-9993
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:77 MEDFORD AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1281
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184808-12085R0202X
NY1848082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01563579Medicaid
NYF90771Medicare UPIN
NY50J611Medicare ID - Type Unspecified