Provider Demographics
NPI:1982605937
Name:ROTHMAN, PETER M (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:M
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 1:7920 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:US
Mailing Address - Phone:260-436-5670
Mailing Address - Fax:260-436-4706
Practice Address - Street 1:7920 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-436-5670
Practice Address - Fax:260-436-4706
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026818A207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100050320AMedicaid
047960AMedicare ID - Type Unspecified
IN100050320AMedicaid