Provider Demographics
NPI:1104809367
Name:ROTHENBERG, LAWRENCE MARK (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:MARK
Last Name:ROTHENBERG
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 1:3015 HWAY 95 STE 105
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-4334
Mailing Address - Country:US
Mailing Address - Phone:928-763-2001
Mailing Address - Fax:928-763-2038
Practice Address - Street 1:3015 HIGHWAY 95 STE 105
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-4334
Practice Address - Country:US
Practice Address - Phone:928-763-2001
Practice Address - Fax:928-763-2038
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ67244207R00000X
FLME27088207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD58832Medicare UPIN
4N0947460Medicare PIN
LAP00602878Medicare PIN
NED58832Medicare UPIN