Provider Demographics
NPI:1194225227
Name:ROTTER, DAVID B (CPO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:ROTTER
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 SPRINGFIELD AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6545
Mailing Address - Country:US
Mailing Address - Phone:815-582-4482
Mailing Address - Fax:630-424-0467
Practice Address - Street 1:121 SPRINGFIELD AVE STE 4
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6545
Practice Address - Country:US
Practice Address - Phone:815-255-3220
Practice Address - Fax:630-424-0467
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213000185222Z00000X
IL211000159224P00000X
IL212000113224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist