Provider Demographics
NPI:1992786552
Name:ROSEN, ELI (MD)
Entity type:Individual
Prefix:
First Name:ELI
Middle Name:
Last Name:ROSEN
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 1:358 KINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-4332
Mailing Address - Country:US
Mailing Address - Phone:718-778-7272
Mailing Address - Fax:718-773-4583
Practice Address - Street 1:358 KINGSTON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-4332
Practice Address - Country:US
Practice Address - Phone:718-778-7272
Practice Address - Fax:718-773-4583
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152998207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00758338Medicaid
NYA400004000Medicare PIN
B87381Medicare UPIN