Provider Demographics
NPI:1366497976
Name:ROTHMAN, GLENN B (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:B
Last Name:ROTHMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2222 E. HIGHLAND AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4876
Mailing Address - Country:US
Mailing Address - Phone:602-257-4219
Mailing Address - Fax:602-257-8319
Practice Address - Street 1:1520 S. DOBSON ROAD
Practice Address - Street 2:SUITE 305
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202
Practice Address - Country:US
Practice Address - Phone:602-539-4000
Practice Address - Fax:602-833-3040
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2010-09-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ23172207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ21316Medicaid
AZ21316Medicaid
78677Medicare PIN
WDBNK01Medicare ID - Type Unspecified