Provider Demographics
NPI:1588124283
Name:ROSEN, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:ROSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 S UNIVERSITY DR STE 5
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2001
Mailing Address - Country:US
Mailing Address - Phone:954-998-0345
Mailing Address - Fax:
Practice Address - Street 1:3501 S UNIVERSITY DR STE 5
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2001
Practice Address - Country:US
Practice Address - Phone:954-998-0345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME160909207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program