Provider Demographics
NPI:1851458228
Name:ROSENFELD, JEROME B (OD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:B
Last Name:ROSENFELD
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 1:1630 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-5403
Mailing Address - Country:US
Mailing Address - Phone:215-545-8100
Mailing Address - Fax:215-546-6120
Practice Address - Street 1:1630 WALNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-5403
Practice Address - Country:US
Practice Address - Phone:215-545-8100
Practice Address - Fax:215-546-6120
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE004920P152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA092951Medicare ID - Type Unspecified
PAT28458Medicare UPIN