Provider Demographics
NPI:1508848748
Name:ROTHSTEIN, LARRY ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:ROBERT
Last Name:ROTHSTEIN
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 1:1030 HARRINGTON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2967
Mailing Address - Country:US
Mailing Address - Phone:586-468-8500
Mailing Address - Fax:586-468-7997
Practice Address - Street 1:1030 HARRINGTON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2967
Practice Address - Country:US
Practice Address - Phone:586-468-8500
Practice Address - Fax:586-468-7997
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILR009607207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2952023Medicaid
MIM08290003Medicare PIN
MI2952023Medicaid