Provider Demographics
NPI:1114923125
Name:ROSENTRATER, DAVID M (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:ROSENTRATER
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 1:1724 W PLYMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:IN
Mailing Address - Zip Code:46506-1940
Mailing Address - Country:US
Mailing Address - Phone:574-546-3045
Mailing Address - Fax:574-546-2716
Practice Address - Street 1:1724 W PLYMOUTH ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:IN
Practice Address - Zip Code:46506-1940
Practice Address - Country:US
Practice Address - Phone:574-546-3045
Practice Address - Fax:574-546-2716
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032844207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100173690Medicaid
IND69740Medicare UPIN
IN206320BMedicare PIN