Provider Demographics
NPI:1356310981
Name:ROTTENBERG, ELISSA B (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:B
Last Name:ROTTENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1400 CENTRE ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NEWTON CENTRE
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2454
Mailing Address - Country:US
Mailing Address - Phone:617-244-9929
Mailing Address - Fax:617-244-9935
Practice Address - Street 1:1400 CENTRE ST
Practice Address - Street 2:SUITE 203
Practice Address - City:NEWTON CENTRE
Practice Address - State:MA
Practice Address - Zip Code:02459-2454
Practice Address - Country:US
Practice Address - Phone:617-244-9929
Practice Address - Fax:617-244-9935
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA215848208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2008491Medicaid