Provider Demographics
NPI:1326094806
Name:ROTEN, DONALD PERRIN JR (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:PERRIN
Last Name:ROTEN
Suffix:JR
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:PO BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 W BANKHEAD ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3101
Practice Address - Country:US
Practice Address - Phone:662-534-7474
Practice Address - Fax:662-534-7100
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16453208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09733845Medicaid
MS09733845Medicaid
MT11457OtherLICENSE