Provider Demographics
NPI:1043326911
Name:ROTHBERG, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:ROTHBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1612
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5801
Mailing Address - Country:US
Mailing Address - Phone:323-857-8000
Mailing Address - Fax:323-857-8008
Practice Address - Street 1:6200 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1612
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5801
Practice Address - Country:US
Practice Address - Phone:323-857-8000
Practice Address - Fax:323-857-8008
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG298942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry