Healthcare Provider Details

I. General information

NPI: 1609223064
Provider Name (Legal Business Name): ETHAN S. ROSENFELD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4930
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1234
  • Fax:
Mailing address:
  • Phone: 505-841-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD88188
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD047589
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number12792806-1205
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD2024-1035
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: