Provider Demographics
NPI:1487747986
Name:ROSENTHAL, ROY (MD)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:
Last Name:ROSENTHAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 NORTH NEVADA AVENUE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-7431
Mailing Address - Country:US
Mailing Address - Phone:719-634-3049
Mailing Address - Fax:719-475-0993
Practice Address - Street 1:1414 NORTH NEVADA AVENUE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-7431
Practice Address - Country:US
Practice Address - Phone:719-634-3049
Practice Address - Fax:719-475-0993
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO200292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO016793OtherVALUE OPTIONS
CO01-200294Medicaid
COC77941Medicare ID - Type Unspecified