Healthcare Provider Details

I. General information

NPI: 1407922404
Provider Name (Legal Business Name): KENNETH MARK ROSENBAUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 S SAN MATEO DR
SAN MATEO CA
94401-3804
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 650-343-4200
  • Fax:
Mailing address:
  • Phone: 650-652-8720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG76294
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: