Healthcare Provider Details

I. General information

NPI: 1821081027
Provider Name (Legal Business Name): DOUGLAS IRA ROSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 E TREMONT AVE 2ND FLOOR
BRONX NY
10465-2022
US

IV. Provider business mailing address

PO BOX 682
BRONX NY
10465-0620
US

V. Phone/Fax

Practice location:
  • Phone: 718-792-4700
  • Fax: 718-828-1898
Mailing address:
  • Phone: 718-792-4700
  • Fax: 718-828-1898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number146634
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: