Provider Demographics
NPI:1558303222
Name:ROTENBERG, DOV (MD)
Entity Type:Individual
Prefix:DR
First Name:DOV
Middle Name:
Last Name:ROTENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 KIMBALL AVE
Mailing Address - Street 2:LL14
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5063
Mailing Address - Country:US
Mailing Address - Phone:319-272-1590
Mailing Address - Fax:319-272-1535
Practice Address - Street 1:2710 SAINT FRANCIS DR
Practice Address - Street 2:SUITE 411
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5619
Practice Address - Country:US
Practice Address - Phone:319-272-5000
Practice Address - Fax:319-272-5825
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA29034207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA7093575Medicaid
IA7093575Medicaid
IA41691Medicare PIN