Provider Demographics
NPI:1942338009
Name:ROSEN, MARK ELLIOT (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ELLIOT
Last Name:ROSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4370 ALPINE RD STE 205
Mailing Address - Street 2:
Mailing Address - City:PORTOLA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94028-7953
Mailing Address - Country:US
Mailing Address - Phone:650-529-0304
Mailing Address - Fax:650-529-1479
Practice Address - Street 1:4370 ALPINE RD STE 205
Practice Address - Street 2:
Practice Address - City:PORTOLA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94028-7953
Practice Address - Country:US
Practice Address - Phone:650-529-0304
Practice Address - Fax:650-529-1479
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2014-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20 A 4880204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A4880Medicare PIN
CAE 08836Medicare UPIN