Healthcare Provider Details

I. General information

NPI: 1780686048
Provider Name (Legal Business Name): STEPHEN L ROTHBLOOM O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 SPRING ROAD
SMYRNA GA
30080
US

IV. Provider business mailing address

1655 SPRING RD SE
SMYRNA GA
30080-3774
US

V. Phone/Fax

Practice location:
  • Phone: 678-842-9544
  • Fax: 678-842-9291
Mailing address:
  • Phone: 678-842-9544
  • Fax: 678-842-9291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1090
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: