Provider Demographics
NPI:1740331628
Name:ROSEN, YITZHAK JOEL (MD)
Entity type:Individual
Prefix:
First Name:YITZHAK
Middle Name:JOEL
Last Name:ROSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOEL
Other - Middle Name:
Other - Last Name:ROSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1640 CALLE MEDICO STE E
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4829
Mailing Address - Country:US
Mailing Address - Phone:505-386-1380
Mailing Address - Fax:505-393-3883
Practice Address - Street 1:1640 CALLE MEDICO STE E
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4829
Practice Address - Country:US
Practice Address - Phone:505-386-1383
Practice Address - Fax:505-393-3883
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2003-0626207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93131224Medicaid
AZ060012Medicaid
AZ060012Medicaid
AZ030073Medicare Oscar/Certification
NM93131224Medicaid
AZ8HE891Medicare UPIN