Provider Demographics
NPI:1295766830
Name:ROSENBERG, RICHARD A (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
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 1:302 SUNSET DR STE 109
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2408
Mailing Address - Country:US
Mailing Address - Phone:423-282-1742
Mailing Address - Fax:
Practice Address - Street 1:302 SUNSET DR STE 109
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2408
Practice Address - Country:US
Practice Address - Phone:423-282-1742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD664152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3594333Medicare ID - Type Unspecified
TNT61183Medicare UPIN