Provider Demographics
NPI:1932845435
Name:LILIENTHAL, ROSALYN ANGELA (OD)
Entity Type:Individual
Prefix:
First Name:ROSALYN
Middle Name:ANGELA
Last Name:LILIENTHAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17249 LAWRENCE WAY
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95949-7175
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 PEACHTREE CT STE H&103A
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4616
Practice Address - Country:US
Practice Address - Phone:844-843-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-07
Last Update Date:2022-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTBD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist