Basic Information
| Provider Information | |||||||||
| NPI: | 1588687255 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSEN | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635 | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917930635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268139988 | ||||||||
| FaxNumber: | 6268130049 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 S SUNSET AVE | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917903940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268142540 | ||||||||
| FaxNumber: | 6268142540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 07/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | C24928 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | C24928 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | C24928 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | C24928 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | C24928 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0203X | C24928 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0204X | C24928 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | C24928 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 00C249280 | 01 | CA | BSBC | OTHER | 00C249280 | 05 | CA | MEDICAID |