Healthcare Provider Details

I. General information

NPI: 1104934124
Provider Name (Legal Business Name): PAUL D ROTTLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 COUCH AVE SUITE 120
SAINT LOUIS MO
63122-5568
US

IV. Provider business mailing address

505 COUCH AVE SUITE 120
SAINT LOUIS MO
63122-5568
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-8880
  • Fax: 314-966-5811
Mailing address:
  • Phone: 314-966-8880
  • Fax: 314-966-5811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberR9G51
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: