Provider Demographics
NPI:1134312358
Name:DR RICHARD A ROSENBERG, OD
Entity Type:Organization
Organization Name:DR RICHARD A ROSENBERG, OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-282-1742
Mailing Address - Street 1:302 SUNSET DRIVE
Mailing Address - Street 2:STE 109
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-9999
Mailing Address - Country:US
Mailing Address - Phone:423-282-1742
Mailing Address - Fax:
Practice Address - Street 1:302 SUNSET DRIVE
Practice Address - Street 2:STE 109
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-9999
Practice Address - Country:US
Practice Address - Phone:423-282-1742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN0664152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3943775Medicaid
TN3943775Medicaid
TN3943775Medicare PIN