Provider Demographics
NPI:1750381307
Name:ROTHFEDER, ROBERT KEITH (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:KEITH
Last Name:ROTHFEDER
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 1:175 W 200 S
Mailing Address - Street 2:STE 4009
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-1413
Mailing Address - Country:US
Mailing Address - Phone:801-359-7756
Mailing Address - Fax:
Practice Address - Street 1:175 W 200 S
Practice Address - Street 2:STE 4009
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-1413
Practice Address - Country:US
Practice Address - Phone:801-359-7756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT158524-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
C63846Medicare UPIN