Provider Demographics
NPI:1033285846
Name:ROTH, BRIAN WILLIAM (MPT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:WILLIAM
Last Name:ROTH
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5676
Mailing Address - Country:US
Mailing Address - Phone:260-432-4700
Mailing Address - Fax:260-459-9262
Practice Address - Street 1:510 N GRANDSTAFF DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706
Practice Address - Country:US
Practice Address - Phone:260-927-9270
Practice Address - Fax:260-927-9272
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007103A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000350992OtherANTHEM BCBS
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IN35179001202OtherCARESOURCE
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IN4423623OtherAETNA
IN1424OtherPHP