Provider Demographics
NPI:1508562067
Name:ROTHBERG, MICHAEL VINCENT
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:VINCENT
Last Name:ROTHBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12625 PACIFIC AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-4331
Mailing Address - Country:US
Mailing Address - Phone:310-498-2991
Mailing Address - Fax:984-220-9462
Practice Address - Street 1:885 TIVERTON DRIVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-4331
Practice Address - Country:US
Practice Address - Phone:310-825-6373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program