Provider Demographics
NPI:1699863621
Name:ROTHENBERG, PETER MORRIS (MD,MA)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:MORRIS
Last Name:ROTHENBERG
Suffix:
Gender:M
Credentials:MD,MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 CAMINO DE LOS MARES
Mailing Address - Street 2:SUITE 137
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2826
Mailing Address - Country:US
Mailing Address - Phone:949-489-9039
Mailing Address - Fax:949-489-8136
Practice Address - Street 1:657 CAMINO DE LOS MARES
Practice Address - Street 2:SUITE 137
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2826
Practice Address - Country:US
Practice Address - Phone:949-489-9039
Practice Address - Fax:949-489-8136
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47158207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG47158OtherCA STATE LICENSE
CA00G471581Medicaid
CA00G471581Medicaid
CAG47158OtherCA STATE LICENSE