Provider Demographics
NPI:1093026411
Name:SREY, ROTHTIDA (DO)
Entity Type:Individual
Prefix:DR
First Name:ROTHTIDA
Middle Name:
Last Name:SREY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 JASPER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-1154
Mailing Address - Country:US
Mailing Address - Phone:515-707-3981
Mailing Address - Fax:
Practice Address - Street 1:31573 RANCHO PUEBLO RD STE 102
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-4854
Practice Address - Country:US
Practice Address - Phone:951-528-2185
Practice Address - Fax:951-527-5651
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13252208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0020A1325200Medicaid