Provider Demographics
NPI:1720160567
Name:ROMAN, ROSA C (DPM)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:C
Last Name:ROMAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:977 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2821
Mailing Address - Country:US
Mailing Address - Phone:973-338-1111
Mailing Address - Fax:973-338-1119
Practice Address - Street 1:977 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2821
Practice Address - Country:US
Practice Address - Phone:973-338-1111
Practice Address - Fax:973-338-1119
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00191600213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1K7458OtherHEALTHNET
NJ6200362OtherGHI
NJ4560809Medicaid
NJ223116190OtherHORIZON BC/BS
NJ223116190OtherHORIZON BC/BS
NJ4560809Medicaid
NJ0724920001Medicare NSC
NJ658692Medicare PIN