Provider Demographics
NPI:1487886099
Name:ROSEN, PREETHA S (MD)
Entity type:Individual
Prefix:
First Name:PREETHA
Middle Name:S
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:PO BOX 8007
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-0507
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3046
Practice Address - Country:US
Practice Address - Phone:208-883-6236
Practice Address - Fax:986-600-4565
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-167972084S0012X, 207QS1201X
WAMD605035022084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2039721Medicaid
WAG8938659Medicare UPIN
WA2039721Medicaid