Provider Demographics
NPI:1114020674
Name:ROTHBURD, JEFFREY S (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:ROTHBURD
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 1:5 WESTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4833
Mailing Address - Country:US
Mailing Address - Phone:516-972-0630
Mailing Address - Fax:631-462-0591
Practice Address - Street 1:5 WESTWOOD CT
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-4833
Practice Address - Country:US
Practice Address - Phone:516-972-0630
Practice Address - Fax:631-462-0591
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131184207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY665123Medicaid
47A631Medicare ID - Type Unspecified
B14970Medicare UPIN