Provider Demographics
NPI:1336110832
Name:ROSEN, ROBERT GLENN (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GLENN
Last Name:ROSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3411
Mailing Address - Country:US
Mailing Address - Phone:321-267-3233
Mailing Address - Fax:321-267-5141
Practice Address - Street 1:850 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3411
Practice Address - Country:US
Practice Address - Phone:321-267-3233
Practice Address - Fax:321-267-5141
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2465213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00179443OtherMEDICARE RAILROAD
FL65433OtherBLUE CROSS BLUE SHEILD
FL65433WMedicare PIN
FLP00179443OtherMEDICARE RAILROAD