Provider Demographics
NPI:1578644241
Name:ROTBERG, NICOLA (MD)
Entity Type:Individual
Prefix:
First Name:NICOLA
Middle Name:
Last Name:ROTBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5880 NE CORNELL RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-9000
Mailing Address - Country:US
Mailing Address - Phone:971-228-8097
Mailing Address - Fax:971-246-5144
Practice Address - Street 1:5880 NE CORNELL RD
Practice Address - Street 2:SUITE C
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-9000
Practice Address - Country:US
Practice Address - Phone:971-228-8097
Practice Address - Fax:971-246-5144
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23173207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287236Medicaid
ORH08032Medicare UPIN
OR287236Medicaid