Basic Information
Provider Information | |||||||||
NPI: | 1891774840 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROTHMAN | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3604 BUSH ST | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276097511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9198767807 | ||||||||
FaxNumber: | 9198768823 | ||||||||
Practice Location | |||||||||
Address1: | 3604 BUSH ST | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276097511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9198767807 | ||||||||
FaxNumber: | 9198768823 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2006 | ||||||||
LastUpdateDate: | 03/24/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 31375 | NC | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 73447 | 01 | NY | BCBS PROVIDER NUMBER | OTHER | 6973447 | 05 | NC |   | MEDICAID |