Provider Demographics
NPI:1952370132
Name:ROSENTHAL, KEITH BRIAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:BRIAN
Last Name:ROSENTHAL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 N COUNTY LINE RD
Mailing Address - Street 2:STE H
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-4421
Mailing Address - Country:US
Mailing Address - Phone:732-833-2800
Mailing Address - Fax:732-833-4808
Practice Address - Street 1:180 N COUNTY LINE RD
Practice Address - Street 2:STE H
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-4421
Practice Address - Country:US
Practice Address - Phone:732-833-2800
Practice Address - Fax:732-833-4808
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00240300213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJTZ7323107Medicaid
NJ959078Medicare ID - Type Unspecified
NJTZ7323107Medicaid