Provider Demographics
NPI:1700907896
Name:ROSENBAUM, JERRY M (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:M
Last Name:ROSENBAUM
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 1:6 BAY COURT
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901
Mailing Address - Country:US
Mailing Address - Phone:305-505-7180
Mailing Address - Fax:415-785-4176
Practice Address - Street 1:6 BAY COURT
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901
Practice Address - Country:US
Practice Address - Phone:305-505-7180
Practice Address - Fax:415-785-4176
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME33938174H00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD64775Medicare UPIN