Basic Information
| Provider Information | |||||||||
| NPI: | 1154346674 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROTHBARTH | ||||||||
| FirstName: | LEO | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 SOUTH ASHLEY DRIVE | ||||||||
| Address2: | SUITE 1500 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336025318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138996220 | ||||||||
| FaxNumber: | 8139858006 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 SOUTH ASHLEY DRIVE | ||||||||
| Address2: | SUITE 1500 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336025318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138996220 | ||||||||
| FaxNumber: | 8139858006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 02/10/2016 | ||||||||
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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 | 2085N0700X | 30191 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0204X | 30191 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | ME125956 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | ME125956 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0204X | ME125956 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01301910 | 05 | CO | MEDICAID | 015956000 | 05 | FL | MEDICAID |