Provider Demographics
NPI:1598869687
Name:ROSENBERG, MARK RICHARD (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2285 CORPORATE CIR
Mailing Address - Street 2:STE 200
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7759
Mailing Address - Country:US
Mailing Address - Phone:702-360-2763
Mailing Address - Fax:949-783-2880
Practice Address - Street 1:20950N TATUM BLVD 350
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4256
Practice Address - Country:US
Practice Address - Phone:480-502-6651
Practice Address - Fax:480-513-8253
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2016-03-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ2245207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00633842OtherRAILROAD MEDICARE WEST DERM OF AZ
P00809240OtherRR MEDICARE 4/2010 UNDER PTAN DP3049
AZ114236Medicare PIN
D47146Medicare UPIN
AZZ131409Medicare PIN
P00809240OtherRR MEDICARE 4/2010 UNDER PTAN DP3049
AZZ122629Medicare PIN