MEDICARE: DR. STEPHEN L ROTHBLOOM O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1090	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	205228732	OTHER	GA	CIGNA
2	205228732	OTHER	GU	PHCS
3	205228732	OTHER	GA	VISION SERVICE PLAN
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	205228732	OTHER	GA	BLUE CROSS BLUE SHIELD
6	205228732	OTHER	GA	UNITED HEALTH CARE
7	205228732	OTHER	GA	VISION CARE PLAN

General Provider Information

NPI Number	:	1780686048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN L ROTHBLOOM O.D.

Provider Business Mailing Address
First Line	:	1655 SPRING RD SE
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-3774
Country	:	US
Telephone Number	:	678-842-9544
Fax Number	:	678-842-9291

Provider Business Practice Location Address
First Line	:	1655 SPRING ROAD
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080
Country	:	US
Telephone Number	:	678-842-9544
Fax Number	:	678-842-9291

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	04/02/2008

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Directions to “ DR. STEPHEN L ROTHBLOOM O.D.” Practice Location

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