Healthcare Provider Details

I. General information

NPI: 1669740338
Provider Name (Legal Business Name): JACK ROTHBERG MD A MEDICAL COPT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 WILSHIRE BLVD SUITE 1612
LOS ANGELES CA
90048
US

IV. Provider business mailing address

6200 WILSHIRE BLVD SUITE 1612
LOS ANGELES CA
90048
US

V. Phone/Fax

Practice location:
  • Phone: 323-857-8000
  • Fax: 323-857-8008
Mailing address:
  • Phone: 323-857-8000
  • Fax: 323-857-8008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberG29894
License Number StateCA

VIII. Authorized Official

Name: JACK ROTHBERG
Title or Position: OWNER
Credential: PHD, MD
Phone: 323-857-8000