Healthcare Provider Details

I. General information

NPI: 1912224221
Provider Name (Legal Business Name): RON ROSEN, M.D., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2010
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 MOORPARK AVE SUITE 220
SAN JOSE CA
95128-2654
US

IV. Provider business mailing address

2211 MOORPARK AVE SUITE 220
SAN JOSE CA
95128-2654
US

V. Phone/Fax

Practice location:
  • Phone: 408-515-4483
  • Fax:
Mailing address:
  • Phone: 408-515-4483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberA96556
License Number StateCA

VIII. Authorized Official

Name: DR. RON SHALOM ROSEN
Title or Position: CEO
Credential: M.D.
Phone: 408-515-4483