Provider Demographics
NPI:1619124583
Name:STEPHEN ROTHBLOOM OD, LLC
Entity Type:Organization
Organization Name:STEPHEN ROTHBLOOM OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTHBLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:678-842-9544
Mailing Address - Street 1:1655 SPRING RD SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-3774
Mailing Address - Country:US
Mailing Address - Phone:678-842-9544
Mailing Address - Fax:678-842-9291
Practice Address - Street 1:1655 SPRING RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-3774
Practice Address - Country:US
Practice Address - Phone:678-842-9544
Practice Address - Fax:678-842-9291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 1090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty