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1609223064

NPI Code Detail

MEDICARE: DR. ETHAN S. ROSENFELD M.D.

MEDICARE: DR. ETHAN S. ROSENFELD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	D88188	MD
2	2086S0129X	Vascular Surgery Physician	MD2024-1035	NM
3	208600000X	Surgery Physician	MD047589	DC
4	2086S0129X	Vascular Surgery Physician	12792806-1205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D88188	OTHER	MD	MD LICENSE
2	MD2024-1035	OTHER	NM	NM LICENSE
3	MD047589	OTHER	DC	DC LICENSE

General Provider Information

NPI Number	:	1609223064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ETHAN S. ROSENFELD M.D.

Provider Business Mailing Address
First Line	:	PO BOX 30180
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84130-0180
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5295 S COMMERCE DR STE 550
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84107-4736
Country	:	US
Telephone Number	:	801-313-4110
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2016
Last Update Date	:	12/31/2025

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Directions to “ DR. ETHAN S. ROSENFELD M.D.” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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