Provider Demographics
NPI:1194706218
Name:ROSENFELD, MICHAEL JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:ROSENFELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 4TH AVE
Mailing Address - Street 2:MAB 3RD FLOOR
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-1898
Mailing Address - Country:US
Mailing Address - Phone:641-236-2905
Mailing Address - Fax:641-236-2907
Practice Address - Street 1:210 4TH AVE
Practice Address - Street 2:MAB 3RD FLOOR
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-1898
Practice Address - Country:US
Practice Address - Phone:641-236-2905
Practice Address - Fax:641-236-2907
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA329572084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA810623397501120000OtherTRICARE #
IA06847OtherBCBS PROV #
IA2186049Medicaid
IAP00120796OtherRR MEDICARE
IA810623397501120000OtherTRICARE #
IA2186049Medicaid
IAH02266Medicare UPIN