Provider Demographics
NPI:1790748556
Name:ROSENBERG, JACK A (M D)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5920 N.E. RAY CIRCLE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-6313
Mailing Address - Country:US
Mailing Address - Phone:503-690-0707
Mailing Address - Fax:503-690-9796
Practice Address - Street 1:5920 N. E. RAY CIRCLE
Practice Address - Street 2:SUITE 220
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-6313
Practice Address - Country:US
Practice Address - Phone:503-690-0707
Practice Address - Fax:503-690-9796
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08402208000000X, 2080A0000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164012Medicaid
G31345Medicare UPIN
OR164012Medicare ID - Type Unspecified
OR164012Medicaid