Provider Demographics
NPI:1467562389
Name:ROTHSTEIN, MARK WILLIAM (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:ROTHSTEIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6507 EDENVALE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3303
Mailing Address - Country:US
Mailing Address - Phone:410-982-6670
Mailing Address - Fax:
Practice Address - Street 1:6507 EDENVALE RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3303
Practice Address - Country:US
Practice Address - Phone:410-982-6670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01451213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0194730OtherBCBS
AZ423468Medicaid
AZAZ0194730OtherBCBS
AZ8HZ40FMedicare ID - Type UnspecifiedPART B
AZ423468Medicaid