Provider Demographics
NPI:1538121504
Name:ROTBERG, LEEMOR BASSE (MD)
Entity Type:Individual
Prefix:
First Name:LEEMOR
Middle Name:BASSE
Last Name:ROTBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LEEMOR
Other - Middle Name:
Other - Last Name:BASSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6689 ORCHARD LAKE ROAD
Mailing Address - Street 2:#297
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322
Mailing Address - Country:US
Mailing Address - Phone:248-254-8140
Mailing Address - Fax:248-254-8150
Practice Address - Street 1:22731 NEWMAN STREET
Practice Address - Street 2:SUITE 245
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124
Practice Address - Country:US
Practice Address - Phone:313-561-1777
Practice Address - Fax:313-561-8044
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078090207WX0110X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4761675Medicaid
MI4761675Medicaid