Basic Information
| Provider Information | |||||||||
| NPI: | 1811982572 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROTHMAN | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3251 N MCMULLEN BOOTH RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337612022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7276696811 | ||||||||
| FaxNumber: | 7276696818 | ||||||||
| Practice Location | |||||||||
| Address1: | 3251 N MCMULLEN BOOTH RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337612022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7276696811 | ||||||||
| FaxNumber: | 7276696818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 07/30/2012 | ||||||||
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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 | 207VG0400X | 0037045 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 065170200 | 05 | FL | MEDICAID |