Provider Demographics
NPI:1609215557
Name:ROTHBERG, KAITLYN CEZANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:KAITLYN
Middle Name:CEZANNE
Last Name:ROTHBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 4TH ST N
Mailing Address - Street 2:STE A
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-4300
Mailing Address - Country:US
Mailing Address - Phone:806-433-7509
Mailing Address - Fax:
Practice Address - Street 1:2201 4TH ST N
Practice Address - Street 2:STE A
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-4300
Practice Address - Country:US
Practice Address - Phone:727-894-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2018-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8258-T152W00000X
FLOPC 4840152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist