Provider Demographics
NPI:1295769255
Name:ROTERMUND, MAYNARD B (MD)
Entity type:Individual
Prefix:DR
First Name:MAYNARD
Middle Name:B
Last Name:ROTERMUND
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 1:210 DOVER DRIVE
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598
Mailing Address - Country:US
Mailing Address - Phone:925-787-4110
Mailing Address - Fax:925-938-4030
Practice Address - Street 1:210 DOVER DRIVE
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598
Practice Address - Country:US
Practice Address - Phone:925-787-4110
Practice Address - Fax:925-938-4030
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG3944174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA56305Medicare UPIN