Provider Demographics
NPI:1306923818
Name:ROSENTHAL, CARLA W (MD)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:W
Last Name:ROSENTHAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 EDGEVALE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210
Mailing Address - Country:US
Mailing Address - Phone:410-323-7902
Mailing Address - Fax:410-255-3617
Practice Address - Street 1:3414 ST PAUL STREET
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218
Practice Address - Country:US
Practice Address - Phone:410-323-7902
Practice Address - Fax:410-255-3617
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD31025207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD350981800Medicaid
MD962RMedicare PIN
MD350981800Medicaid