Provider Demographics
NPI:1164521290
Name:ROSEN, MARC (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:
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 1:32 SUNBROOK RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-1833
Mailing Address - Country:US
Mailing Address - Phone:203-932-5711
Mailing Address - Fax:775-599-1511
Practice Address - Street 1:DEPT OF PSYCHIATRY,116A
Practice Address - Street 2:VA CONNECTICUT HEALTHCARE SYSTEM
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516
Practice Address - Country:US
Practice Address - Phone:203-932-5711
Practice Address - Fax:775-599-1511
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0292112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT029211OtherMEDICAL LICENSE
CTE46116Medicare UPIN