Healthcare Provider Details

I. General information

NPI: 1326066887
Provider Name (Legal Business Name): ROBERT JAY ROTHBAUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND STREET PEDIATRIC GASTROENTEROLOGY, HEPATOLOGY AND NUTRITION
OAKLAND CA
94609
US

IV. Provider business mailing address

747 52ND STREET PEDIATRIC GASTROENTEROLOGY, HEPATOLOGY AND NUTRITION
OAKLAND CA
94609
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3058
  • Fax: 510-450-5813
Mailing address:
  • Phone: 510-428-3058
  • Fax: 510-450-5813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR8845
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberR8845
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberG158847
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: