Provider Demographics
NPI:1780749994
Name:ROTHSTEIN, GREGG J (DC)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:J
Last Name:ROTHSTEIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 BUCHANAN DR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-3253
Mailing Address - Country:US
Mailing Address - Phone:772-353-2740
Mailing Address - Fax:
Practice Address - Street 1:5705 BUCHANAN DR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-3253
Practice Address - Country:US
Practice Address - Phone:772-353-2740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 0004497111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT54959Medicare UPIN
FL65-0160431OtherTAX ID