Provider Demographics
NPI:1255369419
Name:ROSENFELD, GEORGE M (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:M
Last Name:ROSENFELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4819
Mailing Address - Fax:860-632-0240
Practice Address - Street 1:270 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:CT
Practice Address - Zip Code:06480-1857
Practice Address - Country:US
Practice Address - Phone:860-342-3392
Practice Address - Fax:860-358-8658
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT018715207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1187152Medicaid
CTB83699Medicare UPIN
CT080001170Medicare PIN