Basic Information
| Provider Information | |||||||||
| NPI: | 1174577449 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTHROCK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | F. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37174 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212973174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5714235699 | ||||||||
| FaxNumber: | 5714235698 | ||||||||
| Practice Location | |||||||||
| Address1: | 8081 INNOVATION PARK DR STE 900 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5714724200 | ||||||||
| FaxNumber: | 5714724201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 09/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD041880 | DC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 0101275611 | VA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 009991600 | 05 | AL | MEDICAID | 1174577449 | 05 | NV | MEDICAID | 00114706 | 05 | MS | MEDICAID | 11423627 | 01 | CAQH | OTHER | 255687100 | 05 | FL | MEDICAID | 51023614 | 01 | AL | BCBS | OTHER | 000023614 | 05 | AL | MEDICAID | 05-12000 | 01 | AL | UNITED HEALTHCARE | OTHER | 51509740 | 01 | AL | BCBS | OTHER |