Provider Demographics
NPI: | 1801043211 |
---|---|
Name: | ROSENBAUM, RAPHAEL ELIEZER (MD) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | RAPHAEL |
Middle Name: | ELIEZER |
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: | 140 EAST 80TH ST |
Mailing Address - Street 2: | |
Mailing Address - City: | NEW YORK |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 10075-0306 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 212-772-0600 |
Mailing Address - Fax: | 212-517-8028 |
Practice Address - Street 1: | 1316 48TH ST |
Practice Address - Street 2: | |
Practice Address - City: | BROOKLYN |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11219-3167 |
Practice Address - Country: | US |
Practice Address - Phone: | 718-436-8988 |
Practice Address - Fax: | 718-435-8861 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2008-08-27 |
Last Update Date: | 2021-12-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 257453 | 207W00000X, 207WX0108X |
NY | 257453-1 | 207W00000X |
MA | 239531 | 207W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | |
No | 207WX0108X | Allopathic & Osteopathic Physicians | Ophthalmology | Uveitis and Ocular Inflammatory Disease |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 032639003 | Medicaid |