Provider Demographics
NPI:1881652261
Name:ROZENBERG, ILONA (PHYSICAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:ILONA
Middle Name:
Last Name:ROZENBERG
Suffix:
Gender:F
Credentials:PHYSICAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 E 12TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1070
Mailing Address - Country:US
Mailing Address - Phone:917-238-2195
Mailing Address - Fax:718-963-6793
Practice Address - Street 1:374 STOCKHOLM ST
Practice Address - Street 2:C/O FACULTY PRACTIE
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4006
Practice Address - Country:US
Practice Address - Phone:718-963-6551
Practice Address - Fax:718-963-6793
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008221363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02617334Medicaid
NY5670L1Medicare ID - Type Unspecified