Provider Demographics
NPI:1780686048
Name:ROTHBLOOM, STEPHEN L (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:L
Last Name:ROTHBLOOM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 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 ROAD
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080
Practice Address - Country:US
Practice Address - Phone:678-842-9544
Practice Address - Fax:678-842-9291
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA205228732OtherCIGNA
GU205228732OtherPHCS
GA205228732OtherVISION SERVICE PLAN
GA100781Medicaid
GA205228732OtherBLUE CROSS BLUE SHIELD
GA205228732OtherUNITED HEALTH CARE
GA205228732OtherVISION CARE PLAN
GA205228732OtherBLUE CROSS BLUE SHIELD
GA100781Medicaid