Healthcare Provider Details

I. General information

NPI: 1508848748
Provider Name (Legal Business Name): LARRY ROBERT ROTHSTEIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 HARRINGTON ST SUITE 101
MOUNT CLEMENS MI
48043-2967
US

IV. Provider business mailing address

1030 HARRINGTON ST SUITE 101
MOUNT CLEMENS MI
48043-2967
US

V. Phone/Fax

Practice location:
  • Phone: 586-468-8500
  • Fax: 586-468-7997
Mailing address:
  • Phone: 586-468-8500
  • Fax: 586-468-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberLR009607
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: