Provider Demographics
NPI:1568442853
Name:ROTHAAR, ROBERT CHRISTOPHER (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CHRISTOPHER
Last Name:ROTHAAR
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 1:6550 FOUNTAIN LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3764
Mailing Address - Country:US
Mailing Address - Phone:617-699-2594
Mailing Address - Fax:
Practice Address - Street 1:6550 FOUNTAIN LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-3764
Practice Address - Country:US
Practice Address - Phone:617-983-9064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212372207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA39153Medicare ID - Type Unspecified
H10511Medicare UPIN