Provider Demographics
NPI:1659470201
Name:ROSENTHAL, MARK J (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:ROSENTHAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8479 SW 122ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5121
Mailing Address - Country:US
Mailing Address - Phone:305-546-3818
Mailing Address - Fax:
Practice Address - Street 1:975 BAPTIST WAY
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-7600
Practice Address - Country:US
Practice Address - Phone:305-779-7022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 5502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80347Medicare ID - Type Unspecified