Provider Demographics
NPI:1912098559
Name:ROSENBERG, MARK ERNEST (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ERNEST
Last Name:ROSENBERG
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 1:1750 EL CAMINO REAL
Mailing Address - Street 2:SUITE 11
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3228
Mailing Address - Country:US
Mailing Address - Phone:650-692-1373
Mailing Address - Fax:650-692-4209
Practice Address - Street 1:1750 EL CAMINO REAL
Practice Address - Street 2:SUITE 11
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3228
Practice Address - Country:US
Practice Address - Phone:650-692-1373
Practice Address - Fax:650-692-4209
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC33873174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ73137ZMedicaid
CAZZZ73137ZMedicaid
CA00C338730Medicare ID - Type Unspecified