Provider Demographics
NPI:1649373325
Name:ROSEN, NEIL CLIFFORD (OD)
Entity type:Individual
Prefix:
First Name:NEIL
Middle Name:CLIFFORD
Last Name:ROSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2664 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-1422
Mailing Address - Country:US
Mailing Address - Phone:203-333-4828
Mailing Address - Fax:203-336-0049
Practice Address - Street 1:2664 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-1422
Practice Address - Country:US
Practice Address - Phone:203-333-4828
Practice Address - Fax:203-336-0049
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2306152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U40439Medicare UPIN