Provider Demographics
NPI:1730329699
Name:ROTHMAN, JASON ROBERT (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ROBERT
Last Name:ROTHMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 FRASIER ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2125
Mailing Address - Country:US
Mailing Address - Phone:919-477-7003
Mailing Address - Fax:919-471-2827
Practice Address - Street 1:205 FRASIER ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2125
Practice Address - Country:US
Practice Address - Phone:919-477-7003
Practice Address - Fax:919-471-2827
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427102208800000X
NC2009-00596208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2073923Medicare PIN