Provider Demographics
NPI:1790385375
Name:ROSENBAUM, DAVID LEE
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:ROSENBAUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4403
Mailing Address - Country:US
Mailing Address - Phone:276-685-9721
Mailing Address - Fax:
Practice Address - Street 1:127 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4403
Practice Address - Country:US
Practice Address - Phone:276-685-9721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA172A00000X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver