Provider Demographics
NPI:1013905488
Name:ROSENBERG, PETER (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:ROSENBERG
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 1:220 N MCKEMY AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2654
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:480-961-4605
Practice Address - Street 1:3415 W GLENDALE AVE
Practice Address - Street 2:BUILDING B, SUITE 11
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-8386
Practice Address - Country:US
Practice Address - Phone:602-973-5868
Practice Address - Fax:602-973-6076
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ874152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ78542Medicare PIN
AZZ163466Medicare PIN
AZZ163470Medicare PIN
AZZ163468Medicare PIN
AZZ162079Medicare PIN
AZZ162078Medicare PIN
AZZ163469Medicare PIN
AZZ162074Medicare PIN
AZZ162076Medicare PIN
AZZ162075Medicare PIN
AZZ163465Medicare PIN
AZZ163467Medicare PIN
AZT70189Medicare UPIN
AZZ162077Medicare PIN