Provider Demographics
NPI:1710085303
Name:ROSENBLATT, JACK ELLIOT (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ELLIOT
Last Name:ROSENBLATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:ELLIOT
Other - Last Name:ROSENBLATT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:7000 CARMICHAEL AVE
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-4612
Mailing Address - Country:US
Mailing Address - Phone:301-873-7904
Mailing Address - Fax:301-320-0856
Practice Address - Street 1:7000 CARMICHAEL AVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-4612
Practice Address - Country:US
Practice Address - Phone:301-873-7904
Practice Address - Fax:301-320-0856
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0018209101YM0800X
MDD182092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
C62643Medicare UPIN