Provider Demographics
NPI:1790881852
Name:ROSENBAUM, ALFRED (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:
Last Name:ROSENBAUM
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 1:1500 ROUTE 112 BLDG 4
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8055
Mailing Address - Country:US
Mailing Address - Phone:631-751-3000
Mailing Address - Fax:631-509-6559
Practice Address - Street 1:1421 3RD AVE
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-1802
Practice Address - Country:US
Practice Address - Phone:212-744-5538
Practice Address - Fax:212-744-4767
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1164422085R0001X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1790881852OtherNPI
NYB77897Medicare UPIN
NY571711Medicare ID - Type Unspecified