Provider Demographics
NPI:1346295870
Name:ROSEN, LEE S (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:S
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 1:4550 RUBIO AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-3202
Mailing Address - Country:US
Mailing Address - Phone:818-783-1380
Mailing Address - Fax:
Practice Address - Street 1:2020 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 510
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2023
Practice Address - Country:US
Practice Address - Phone:310-633-8400
Practice Address - Fax:310-633-8419
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49741174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49741OtherMEDICAL LICENSE
CAG35932Medicare UPIN
CAW17316Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER