Provider Demographics
NPI:1144291931
Name:ROSEN, KENNETH B (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:B
Last Name:ROSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26-07 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3832
Mailing Address - Country:US
Mailing Address - Phone:201-796-3050
Mailing Address - Fax:201-796-3385
Practice Address - Street 1:26-07 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3832
Practice Address - Country:US
Practice Address - Phone:201-796-3050
Practice Address - Fax:201-796-3385
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00349600152W00000X
NJ27T000072100152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
U26854Medicare UPIN
NJ0125660001Medicare NSC