Healthcare Provider Details

I. General information

NPI: 1619275203
Provider Name (Legal Business Name): GARY JOEL ROSENBERG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2011
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 OLD NEWPORT BLVD
NEWPORT BEACH CA
92663-4210
US

IV. Provider business mailing address

441 OLD NEWPORT BLVD
NEWPORT BEACH CA
92663-4210
US

V. Phone/Fax

Practice location:
  • Phone: 949-491-9991
  • Fax:
Mailing address:
  • Phone: 949-491-9991
  • Fax: 949-612-9795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number20A15694
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number20A15694
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number5101020846
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: