Healthcare Provider Details

I. General information

NPI: 1942338009
Provider Name (Legal Business Name): MARK ELLIOT ROSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 02/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4370 ALPINE RD STE 205
PORTOLA VALLEY CA
94028-7953
US

IV. Provider business mailing address

4370 ALPINE RD STE 205
PORTOLA VALLEY CA
94028-7953
US

V. Phone/Fax

Practice location:
  • Phone: 650-529-0304
  • Fax: 650-529-1479
Mailing address:
  • Phone: 650-529-0304
  • Fax: 650-529-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number20 A 4880
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: