Provider Demographics
NPI:1598895898
Name:ROSEN, JEFFREY M (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:M
Last Name:ROSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 SUNRISE MALL
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-4340
Mailing Address - Country:US
Mailing Address - Phone:516-795-3030
Mailing Address - Fax:516-795-2418
Practice Address - Street 1:224 SUNRISE MALL
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-4340
Practice Address - Country:US
Practice Address - Phone:516-795-3030
Practice Address - Fax:516-795-2418
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY 003430-0152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11-3270311OtherTAX ID#
NYC1251YRRP1Medicare PIN