Provider Demographics
NPI:1740316033
Name:ROSEN, DANIEL MARK (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:MARK
Last Name:ROSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5385 W CENTINELA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-2003
Mailing Address - Country:US
Mailing Address - Phone:310-670-7422
Mailing Address - Fax:310-670-4570
Practice Address - Street 1:5385 W CENTINELA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-2003
Practice Address - Country:US
Practice Address - Phone:310-670-7422
Practice Address - Fax:310-670-4570
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10860T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0108600Medicaid
CAU95661Medicare UPIN
CASD0108600Medicaid