Provider Demographics
NPI:1295763407
Name:ROSEN, TODD (MD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:
Last Name:ROSEN
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 1:420 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2445
Mailing Address - Country:US
Mailing Address - Phone:810-275-3724
Mailing Address - Fax:810-257-3731
Practice Address - Street 1:420 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2445
Practice Address - Country:US
Practice Address - Phone:810-275-3724
Practice Address - Fax:810-257-3731
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0494642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4166893Medicaid
MIMH1111119OtherHEALTHPLUS OF MI
MI260B56093OtherBCBS
MI260B56093OtherBCBS
MI4166893Medicaid