Provider Demographics
NPI:1588649271
Name:ROTTNEK, FRED W (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:W
Last Name:ROTTNEK
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 1:1402 S GRAND BLVD
Mailing Address - Street 2:FAMILY AND COMMUNITY MEDICINE
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1004
Mailing Address - Country:US
Mailing Address - Phone:314-977-8489
Mailing Address - Fax:
Practice Address - Street 1:1402 S GRAND BLVD
Practice Address - Street 2:FAMILY AND COMMUNITY MEDICINE
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1004
Practice Address - Country:US
Practice Address - Phone:314-977-8489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204968416Medicaid
H10399Medicare UPIN
MO214010753Medicare ID - Type Unspecified