Provider Demographics
NPI:1326066887
Name:ROTHBAUM, ROBERT JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JAY
Last Name:ROTHBAUM
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 1:747 52ND STREET
Mailing Address - Street 2:PEDIATRIC GASTROENTEROLOGY, HEPATOLOGY AND NUTRITION
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609
Mailing Address - Country:US
Mailing Address - Phone:510-428-3058
Mailing Address - Fax:510-450-5813
Practice Address - Street 1:747 52ND STREET
Practice Address - Street 2:PEDIATRIC GASTROENTEROLOGY, HEPATOLOGY AND NUTRITION
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609
Practice Address - Country:US
Practice Address - Phone:510-428-3058
Practice Address - Fax:510-450-5813
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8845208000000X, 2080P0206X
CAG1588472080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202032207Medicaid
ILENROLLEDMedicaid
MO103810161Medicaid
MO103810161Medicare PIN