Healthcare Provider Details

I. General information

NPI: 1114900925
Provider Name (Legal Business Name): BONNIE SUE ROSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MEDFORD AVE
PATCHOGUE NY
11772-1281
US

IV. Provider business mailing address

3 SCENIC VIEW CT EAST
DIX HILLS NY
11746
US

V. Phone/Fax

Practice location:
  • Phone: 952-595-1100
  • Fax: 612-294-4903
Mailing address:
  • Phone: 516-901-9993
  • Fax: 612-294-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number184808-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number184808
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: