Provider Demographics
NPI:1245333780
Name:ROTHENBACH, THOMAS A (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:ROTHENBACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:P
Other - Middle Name:A
Other - Last Name:ROTHENBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-7080
Practice Address - Fax:682-885-7085
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK249532086S0120X
TXK53932086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200091680AMedicaid
TX202455601Medicaid
TXK5393OtherTEXAS STATE BOARD OF MEDICAL EXAMINERS