Provider Demographics
NPI:1083363931
Name:ROTH, WARREN JOSEPH (MEDICAL STUDENT)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:JOSEPH
Last Name:ROTH
Suffix:
Gender:M
Credentials:MEDICAL STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3814 VILLAGE PARK DR
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-5747
Mailing Address - Country:US
Mailing Address - Phone:202-412-4805
Mailing Address - Fax:
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-0100
Practice Address - Country:US
Practice Address - Phone:202-412-4805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-19
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program