Provider Demographics
NPI:1649284100
Name:ROTMAN, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ROTMAN
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 1:290 CENTRAL AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559
Mailing Address - Country:US
Mailing Address - Phone:516-239-8877
Mailing Address - Fax:516-239-1104
Practice Address - Street 1:290 CENTRAL AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559
Practice Address - Country:US
Practice Address - Phone:516-239-8877
Practice Address - Fax:516-239-1104
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210711208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02602399Medicaid
NY02602399Medicaid
H66193Medicare UPIN
37R361Medicare PIN