Provider Demographics
NPI:1891774840
Name:ROTHMAN, MARK DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:ROTHMAN
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 1:3604 BUSH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7511
Mailing Address - Country:US
Mailing Address - Phone:919-876-7807
Mailing Address - Fax:919-876-8823
Practice Address - Street 1:3604 BUSH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7511
Practice Address - Country:US
Practice Address - Phone:919-876-7807
Practice Address - Fax:919-876-8823
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31375174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY73447OtherBCBS PROVIDER NUMBER
NC6973447Medicaid
NY73447OtherBCBS PROVIDER NUMBER
NCD62808Medicare UPIN