Provider Demographics
NPI:1679558282
Name:ROSENBERG, DEAN ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:ALAN
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 6TH ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1213
Mailing Address - Country:US
Mailing Address - Phone:262-634-4430
Mailing Address - Fax:262-634-1890
Practice Address - Street 1:217 6TH ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1213
Practice Address - Country:US
Practice Address - Phone:262-634-4430
Practice Address - Fax:262-634-1890
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2220TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38574400Medicaid
WIP00435918OtherRAILROAD MEDICARE PART B
WI391951110OtherOLD MEDICARE PIN
WI4892040001Medicare NSC
WI000147373Medicare PIN
WIP00435918OtherRAILROAD MEDICARE PART B
WIP00435918OtherRAILROAD MEDICARE PART B