Provider Demographics
NPI:1487634986
Name:ROTHENBERG, RONALD I (DO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:I
Last Name:ROTHENBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 W MAPLE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017
Mailing Address - Country:US
Mailing Address - Phone:248-435-2028
Mailing Address - Fax:248-435-2099
Practice Address - Street 1:909 W MAPLE RD
Practice Address - Street 2:STE 100
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017
Practice Address - Country:US
Practice Address - Phone:248-435-2028
Practice Address - Fax:248-435-2099
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101005522207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080F319020OtherBLUE CROSS
MI1028982Medicaid
0N48670002Medicare ID - Type Unspecified
MI1028982Medicaid