Healthcare Provider Details

I. General information

NPI: 1124299904
Provider Name (Legal Business Name): VANESSA SHANA ROTHHOLTZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2008
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 N CAMDEN DR STE 975
BEVERLY HILLS CA
90210-4541
US

IV. Provider business mailing address

414 N CAMDEN DR STE 975
BEVERLY HILLS CA
90210-4541
US

V. Phone/Fax

Practice location:
  • Phone: 310-926-1573
  • Fax: 310-926-1563
Mailing address:
  • Phone: 310-201-0717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA98964
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: