Provider Demographics
NPI:1225007560
Name:ROSENTHAL, ELYSSA PETERS (MD)
Entity Type:Individual
Prefix:
First Name:ELYSSA
Middle Name:PETERS
Last Name:ROSENTHAL
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 1:3200 E CAMELBACK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1814
Mailing Address - Fax:
Practice Address - Street 1:9305 W THOMAS RD STE 460
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037
Practice Address - Country:US
Practice Address - Phone:602-933-3937
Practice Address - Fax:602-933-2409
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34929207WX0110X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ111668Medicaid
I39055Medicare UPIN