Provider Demographics
NPI:1609823426
Name:ROSEN, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:ROSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5911 FASHION BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7385
Mailing Address - Country:US
Mailing Address - Phone:801-269-1333
Mailing Address - Fax:801-261-2288
Practice Address - Street 1:5911 FASHION BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7352
Practice Address - Country:US
Practice Address - Phone:801-269-1333
Practice Address - Fax:801-261-2288
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT181976-8905174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE70083Medicare UPIN
UT005815701Medicare PIN
UT5576640001Medicare NSC