Provider Demographics
NPI:1104902683
Name:ROTHSTEIN, MICAH W (MD)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:W
Last Name:ROTHSTEIN
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 1:1400 DRY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-6499
Mailing Address - Country:US
Mailing Address - Phone:303-772-3300
Mailing Address - Fax:
Practice Address - Street 1:1400 DRY CREEK DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6505
Practice Address - Country:US
Practice Address - Phone:303-772-3300
Practice Address - Fax:303-682-3380
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43772207W00000X, 207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38605236Medicaid
CO38605236Medicaid
COH93245Medicare UPIN