Provider Demographics
NPI:1518306943
Name:ROTHBERG, ANDREW SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:SCOTT
Last Name:ROTHBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12950 RACE TRACK RD STE 111
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1304
Mailing Address - Country:US
Mailing Address - Phone:813-854-9000
Mailing Address - Fax:813-579-2063
Practice Address - Street 1:12950 RACE TRACK RD STE 111
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1304
Practice Address - Country:US
Practice Address - Phone:813-854-9000
Practice Address - Fax:813-579-2063
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4809152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHM379YMedicare PIN