Provider Demographics
NPI:1356376206
Name:ROSEN, JEFFREY DAVID (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DAVID
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:PO BOX 558
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:VT
Mailing Address - Zip Code:05149-0558
Mailing Address - Country:US
Mailing Address - Phone:716-863-2907
Mailing Address - Fax:
Practice Address - Street 1:700 N BROAD ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-2310
Practice Address - Country:US
Practice Address - Phone:888-428-4588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07901100207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0104361Medicaid