Provider Demographics
NPI:1881790749
Name:ROSEN, THEODORE (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
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 1:2815 PLUMB ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77005-3055
Mailing Address - Country:US
Mailing Address - Phone:713-667-2267
Mailing Address - Fax:
Practice Address - Street 1:1977 BUTLER BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4101
Practice Address - Country:US
Practice Address - Phone:713-798-6131
Practice Address - Fax:713-794-7863
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7258207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123884202Medicaid
TXP00090138Medicare PIN
TX123884202Medicaid
83511FMedicare PIN
TXTXB114776Medicare PIN