Provider Demographics
NPI:1881602985
Name:ROSEN, MARVIN - (MD)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:-
Last Name:ROSEN
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 1:6663 SW BEAVERTON HILLSDALE HWY PMB #291
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-1403
Mailing Address - Country:US
Mailing Address - Phone:503-396-6661
Mailing Address - Fax:503-296-6661
Practice Address - Street 1:131 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4167
Practice Address - Country:US
Practice Address - Phone:503-253-6754
Practice Address - Fax:503-253-8020
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR81562084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165-175Medicaid
OR165-175Medicaid
A08080Medicare UPIN