Healthcare Provider Details

I. General information

NPI: 1821034042
Provider Name (Legal Business Name): IVAN STEWART ROSENTHAL OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 11/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 NE 44TH ST
OAKLAND PARK FL
33334-1437
US

IV. Provider business mailing address

9858 GLADES RD STE D-2
BOCA RATON FL
33434-3982
US

V. Phone/Fax

Practice location:
  • Phone: 561-487-0818
  • Fax: 561-487-9030
Mailing address:
  • Phone: 561-487-0818
  • Fax: 561-487-9030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC1248
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: