Provider Demographics
NPI:1205894821
Name:ROSENTHAL, JORDAN SCOTT (DPM)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:SCOTT
Last Name:ROSENTHAL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:J
Other - Middle Name:SCOTT
Other - Last Name:ROSENTHAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:9100 SO SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-4849
Mailing Address - Country:US
Mailing Address - Phone:310-645-3338
Mailing Address - Fax:310-645-0823
Practice Address - Street 1:9100 SO SEPULVEDA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-4849
Practice Address - Country:US
Practice Address - Phone:310-645-3338
Practice Address - Fax:310-645-0823
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3436213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA213E00000XOtherMEDICARE TYPE-
CA4692830001Medicare NSC
CA213E00000XOtherMEDICARE TYPE-