Healthcare Provider Details

I. General information

NPI: 1699863621
Provider Name (Legal Business Name): PETER MORRIS ROTHENBERG M.D.,M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

657 CAMINO DE LOS MARES SUITE 137
SAN CLEMENTE CA
92673-2826
US

IV. Provider business mailing address

657 CAMINO DE LOS MARES SUITE 137
SAN CLEMENTE CA
92673-2826
US

V. Phone/Fax

Practice location:
  • Phone: 949-489-9039
  • Fax: 949-489-8136
Mailing address:
  • Phone: 949-489-9039
  • Fax: 949-489-8136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberG47158
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: