Basic Information
| Provider Information | |||||||||
| NPI: | 1548264013 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSEN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 N SEPULVEDA BLVD | ||||||||
| Address2: | # 747 | ||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902665111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145340547 | ||||||||
| FaxNumber: | 7144567547 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 THE CITY DR S | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145340547 | ||||||||
| FaxNumber: | 7144567547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2005 | ||||||||
| LastUpdateDate: | 04/30/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/16/2006 | ||||||||
| NPIReactivationDate: | 03/22/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | G53395 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 00G533950 | 05 | CA | MEDICAID |