Provider Demographics
NPI:1780734582
Name:ROTAN, EDWARD EARL JR (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:EARL
Last Name:ROTAN
Suffix:JR
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 1:19772 MACARTHUR BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2413
Mailing Address - Country:US
Mailing Address - Phone:949-975-0620
Mailing Address - Fax:949-975-0628
Practice Address - Street 1:715 N FIELDER RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4695
Practice Address - Country:US
Practice Address - Phone:817-261-1626
Practice Address - Fax:817-275-0441
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91946207N00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A919461OtherINDIVIDUAL PTAN NO. CA.
CAP00375737OtherRAILROAD MEDICARE
CA00A919464Medicare PIN
CAP00375737OtherRAILROAD MEDICARE
CAAO196VMedicare PIN
CAAO196YMedicare PIN
AZ120645Medicare PIN
CA00A919463Medicare PIN
AZ120486Medicare PIN
CA00A919462Medicare PIN
CA00A919461OtherINDIVIDUAL PTAN NO. CA.
CAI42799Medicare UPIN