Provider Demographics
NPI:1174624639
Name:ROSEN, STEPHANIE L (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:L
Last Name:ROSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 E SHORE RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-2415
Mailing Address - Country:US
Mailing Address - Phone:516-487-4020
Mailing Address - Fax:516-487-4039
Practice Address - Street 1:173 E SHORE RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-2415
Practice Address - Country:US
Practice Address - Phone:516-487-4020
Practice Address - Fax:516-487-4039
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206384208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG29691Medicare UPIN