Basic Information
Provider Information | |||||||||
NPI: | 1396962445 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSENFELD-O'TOOL | ||||||||
FirstName: | SANDRA | ||||||||
MiddleName: | ROSANNA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 933 BRADBURY DR SE STE 2222 | ||||||||
Address2: |   | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871064375 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052721476 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2400 TUCKER NE | ||||||||
Address2: |   | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871311009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5052721734 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2007 | ||||||||
LastUpdateDate: | 09/24/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 32995 | IA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 036113944 | IL | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD2018-0740 | NM | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 13238 | 01 | IA | MEDICARE PART B GROUP | OTHER | 16D0387805 | 01 | IA | CLIA | OTHER | 13238 | 01 | IA | BC/BS IA GROUP | OTHER | 1238353 | 01 | IA | CSA # | OTHER | 31319 | 01 | IA | BC/BS IA INDIVIDUAL | OTHER | 421060724002 | 05 | IL |   | MEDICAID | FR0269793 | 01 | IA | DEA # | OTHER | 0080200 | 05 | IA |   | MEDICAID | 16-1801 | 01 | IA | FQHC GROUP UGS | OTHER | 71503 | 01 | IA | WELLMARK BCBS | OTHER |