Provider Demographics
NPI:1679686471
Name:ROSENTHAL, KENNETH G (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:G
Last Name:ROSENTHAL
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 1:5360 NESCONSET HWY
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2018
Mailing Address - Country:US
Mailing Address - Phone:631-331-2121
Mailing Address - Fax:631-509-5611
Practice Address - Street 1:5360 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2018
Practice Address - Country:US
Practice Address - Phone:631-331-3221
Practice Address - Fax:631-509-5611
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2010-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125944207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY293771Medicare ID - Type Unspecified
C07949Medicare UPIN
NYA400033952Medicare PIN