Provider Demographics
NPI:1487744421
Name:ROSENTHAL, MICHAEL KENNETH (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENNETH
Last Name:ROSENTHAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-1392
Mailing Address - Country:US
Mailing Address - Phone:302-652-3469
Mailing Address - Fax:302-652-7102
Practice Address - Street 1:2300 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 3C
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-1392
Practice Address - Country:US
Practice Address - Phone:302-652-3469
Practice Address - Fax:302-652-7102
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0006433207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000030201Medicaid
DEP00124364OtherRAILROAD MEDICARE
DEH64788Medicare UPIN
DE1000030201Medicaid