Provider Demographics
NPI:1790774883
Name:ROTHFLEISCH, JEREMY (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:ROTHFLEISCH
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 1:603 CRANBURY RD
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-4031
Mailing Address - Country:US
Mailing Address - Phone:732-545-5366
Mailing Address - Fax:732-254-1038
Practice Address - Street 1:603 CRANBURY RD
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-4031
Practice Address - Country:US
Practice Address - Phone:732-545-5366
Practice Address - Fax:732-254-1038
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA72361174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
047572Medicare PIN
NJ047572Medicare ID - Type UnspecifiedPROVIDER ID