Provider Demographics
NPI:1821034042
Name:ROSENTHAL, IVAN STEWART (OD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:STEWART
Last Name:ROSENTHAL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9858 GLADES RD
Mailing Address - Street 2:STE D-2
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-3982
Mailing Address - Country:US
Mailing Address - Phone:561-487-0818
Mailing Address - Fax:561-487-9030
Practice Address - Street 1:23 NE 44TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-1437
Practice Address - Country:US
Practice Address - Phone:561-487-0818
Practice Address - Fax:561-487-9030
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1248152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620511900Medicaid
FL410027418OtherMEDICARE RR
FL410027418OtherMEDICARE RR
FL620511900Medicaid
FL0690610001Medicare NSC