Provider Demographics
NPI:1447440433
Name:ROTHMAN, ILAN JOSE (MD)
Entity type:Individual
Prefix:DR
First Name:ILAN
Middle Name:JOSE
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:PO BOX 2040
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2040
Mailing Address - Country:US
Mailing Address - Phone:503-299-9906
Mailing Address - Fax:503-225-9002
Practice Address - Street 1:120 NW 14TH AVE
Practice Address - Street 2:STE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2643
Practice Address - Country:US
Practice Address - Phone:503-299-9906
Practice Address - Fax:503-225-9002
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL17378390200000X
ORMD28510207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR025298Medicaid
WA8524738Medicaid
ORP00695329OtherRR MEDICARE
ORR143762Medicare PIN