Provider Demographics
NPI:1801982095
Name:ROTHBERG, SARA ROSHANNA (MD)
Entity type:Individual
Prefix:DR
First Name:SARA
Middle Name:ROSHANNA
Last Name:ROTHBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2345 CHESTERFIELD AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1062
Mailing Address - Country:US
Mailing Address - Phone:304-344-2900
Mailing Address - Fax:304-344-9385
Practice Address - Street 1:2345 CHESTERFIELD AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1062
Practice Address - Country:US
Practice Address - Phone:304-344-2900
Practice Address - Fax:304-344-9385
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV14112207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001721506Medicaid
WV550722686OtherPRACTICE TAX ID#
WV001721506Medicaid
WV550722686OtherPRACTICE TAX ID#