Provider Demographics
NPI:1720037948
Name:ROTHSTEIN, SUSAN
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:ROTHSTEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 WICKS RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4429
Mailing Address - Country:US
Mailing Address - Phone:631-499-2663
Mailing Address - Fax:
Practice Address - Street 1:285 SILLS RD
Practice Address - Street 2:BLDG.15, SUITE D
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4869
Practice Address - Country:US
Practice Address - Phone:631-758-5858
Practice Address - Fax:631-758-1926
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003273133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9238E1Medicare ID - Type Unspecified