Provider Demographics
NPI:1588657639
Name:ROTHBAUM, KENNETH LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LAWRENCE
Last Name:ROTHBAUM
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 1:2 VILLAGE SQ
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-1624
Mailing Address - Country:US
Mailing Address - Phone:410-433-7433
Mailing Address - Fax:410-433-1663
Practice Address - Street 1:2 VILLAGE SQ
Practice Address - Street 2:SUITE 210
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-1624
Practice Address - Country:US
Practice Address - Phone:410-433-7433
Practice Address - Fax:410-433-1663
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDB270072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB27007OtherMEDICAL LICENSE NUMBER
MD7354Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
MDB27007OtherMEDICAL LICENSE NUMBER