Provider Demographics
NPI:1356920458
Name:ROSENBERG, JOEL
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1952 REED AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-1319
Mailing Address - Country:US
Mailing Address - Phone:612-695-6528
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR # 7897
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1911
Practice Address - Country:US
Practice Address - Phone:858-249-0894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1356920458208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program