Provider Demographics
NPI:1730100124
Name:ROTENBERG, JACK STUART (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:STUART
Last Name:ROTENBERG
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 1:2241 WANKEL WAY
Mailing Address - Street 2:STE. A.
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-0190
Mailing Address - Country:US
Mailing Address - Phone:805-983-0521
Mailing Address - Fax:805-983-4186
Practice Address - Street 1:2241 WANKEL WAY
Practice Address - Street 2:STE. A.
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-0190
Practice Address - Country:US
Practice Address - Phone:805-983-0521
Practice Address - Fax:805-983-4186
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24099207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA953053865OtherTRICARE
CAZZZ76011ZMedicaid
CAZZZ76011ZMedicaid
CAW2289Medicare ID - Type Unspecified