Basic Information
| Provider Information | |||||||||
| NPI: | 1225007560 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSENTHAL | ||||||||
| FirstName: | ELYSSA | ||||||||
| MiddleName: | PETERS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331814 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9305 W THOMAS RD STE 460 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029333937 | ||||||||
| FaxNumber: | 6029332409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 05/31/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0110X | 34929 | AZ | Y | 207W00000X | 34929 | AZ | N | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 111668 | 05 | AZ | MEDICAID |