Provider Demographics
NPI:1336179340
Name:ROSENBERG, JASON G (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:G
Last Name:ROSENBERG
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 1:1121 E NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3515
Mailing Address - Country:US
Mailing Address - Phone:414-267-6502
Mailing Address - Fax:414-267-3892
Practice Address - Street 1:2350 N LAKE DR STE 300
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-298-7100
Practice Address - Fax:414-298-7101
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44786207Q00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1336179340Medicaid
WI1336179340Medicaid