Provider Demographics
NPI:1326132184
Name:ROTHBERG, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
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 1:331 EAST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772
Mailing Address - Country:US
Mailing Address - Phone:631-758-5300
Mailing Address - Fax:631-758-5301
Practice Address - Street 1:331 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-758-5300
Practice Address - Fax:631-758-5301
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165064207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01020864Medicaid
NY01E642OtherEMPIRE BCBS
1688OtherVYTRA HEALTHCARE
CS755OtherOXFORD HEALTHCARE
NY01020864Medicaid
NY01E642Medicare PIN