Provider Demographics
NPI:1295885630
Name:ROSENBERG, FREDRIC ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:FREDRIC
Middle Name:ROBERT
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 1:3650 E. SOUTH STREET
Mailing Address - Street 2:#306
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712
Mailing Address - Country:US
Mailing Address - Phone:310-378-1915
Mailing Address - Fax:310-378-6979
Practice Address - Street 1:3650 E. SOUTH STREET
Practice Address - Street 2:#306
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712
Practice Address - Country:US
Practice Address - Phone:310-378-1915
Practice Address - Fax:310-378-6979
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21402207N00000X, 207NI0002X, 207NS0135X, 207ND0900X, 207NP0225X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4024334OtherAETNA
CA00G214020Medicaid
CAG21402OtherSTATE LICENSE
CAZZZ12556ZOtherBLUE SHIELD
CAZZZ12556ZOtherBLUE SHIELD
CA00G214020Medicaid