Provider Demographics
NPI:1417939638
Name:ROTTO, MARY MATHEWS (PAC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MATHEWS
Last Name:ROTTO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 DUFF AVE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-5733
Mailing Address - Country:US
Mailing Address - Phone:515-239-6970
Mailing Address - Fax:515-239-6950
Practice Address - Street 1:1015 DUFF AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-5733
Practice Address - Country:US
Practice Address - Phone:515-239-6970
Practice Address - Fax:515-239-6950
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00870207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0150599Medicaid
P09412Medicare UPIN