Provider Demographics
NPI:1548264013
Name:ROSEN, CHARLES DAVID (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAVID
Last Name:ROSEN
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 1:1601 N SEPULVEDA BLVD
Mailing Address - Street 2:# 747
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5111
Mailing Address - Country:US
Mailing Address - Phone:714-534-0547
Mailing Address - Fax:714-456-7547
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-534-0547
Practice Address - Fax:714-456-7547
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-12
Last Update Date:2010-04-30
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
CAG53395207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G533950Medicaid
CACW401ZMedicare PIN
CAE02732Medicare UPIN
CA00G533950Medicaid