Provider Demographics
NPI:1730384439
Name:ROSENBERG, GARY A (DPT)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5449 PRIMAVERA DR
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-8000
Mailing Address - Country:US
Mailing Address - Phone:801-915-6649
Mailing Address - Fax:
Practice Address - Street 1:5449 PRIMAVERA DR
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-8000
Practice Address - Country:US
Practice Address - Phone:801-915-6649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6408225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist