Healthcare Provider Details

I. General information

NPI: 1689659831
Provider Name (Legal Business Name): LESLIE B. ROSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 05/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 SW 30TH AVE SUITE 101
POMPANO BEACH FL
33069-4887
US

IV. Provider business mailing address

14275 MIDWAY RD SUITE 400
ADDISON TX
75001-3614
US

V. Phone/Fax

Practice location:
  • Phone: 954-633-3387
  • Fax: 954-633-3217
Mailing address:
  • Phone: 954-633-3387
  • Fax: 610-271-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberME36847
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME36847
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: