Provider Demographics
NPI:1083612444
Name:ROTH, ALAN I (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:I
Last Name:ROTH
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 6864
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-0864
Mailing Address - Country:US
Mailing Address - Phone:502-933-9902
Mailing Address - Fax:502-933-5085
Practice Address - Street 1:5129 DIXIE HWY STE 105
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-1729
Practice Address - Country:US
Practice Address - Phone:502-933-9902
Practice Address - Fax:502-933-5085
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21471207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY185 1401Medicare ID - Type Unspecified
KYD08096Medicare UPIN
KY4459520001Medicare NSC