Healthcare Provider Details

I. General information

NPI: 1467080838
Provider Name (Legal Business Name): BRETT ROZEBOOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 4TH ST N
FARGO ND
58102-4539
US

IV. Provider business mailing address

820 4TH ST N
FARGO ND
58102-4539
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-7459
  • Fax: 701-234-7142
Mailing address:
  • Phone: 701-234-7459
  • Fax: 701-234-7142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number19951
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: