Provider Demographics
NPI:1811982572
Name:ROTHMAN, JACK N (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:N
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 1:3251 N MCMULLEN BOOTH RD
Mailing Address - Street 2:STE 102
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-2022
Mailing Address - Country:US
Mailing Address - Phone:727-669-6811
Mailing Address - Fax:727-669-6818
Practice Address - Street 1:3251 N MCMULLEN BOOTH RD
Practice Address - Street 2:STE 102
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-2022
Practice Address - Country:US
Practice Address - Phone:727-669-6811
Practice Address - Fax:727-669-6818
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0037045207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065170200Medicaid
FL62279Medicare ID - Type Unspecified
FL065170200Medicaid