Provider Demographics
NPI:1821081027
Name:ROSEN, DOUGLAS IRA (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:IRA
Last Name:ROSEN
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:PO BOX 682
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-0620
Mailing Address - Country:US
Mailing Address - Phone:718-792-4700
Mailing Address - Fax:718-828-1898
Practice Address - Street 1:3620 E TREMONT AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-2022
Practice Address - Country:US
Practice Address - Phone:718-792-4700
Practice Address - Fax:718-828-1898
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146634207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00806235Medicaid
NY00806235Medicaid
NY070591Medicare ID - Type Unspecified