Provider Demographics
NPI:1093924987
Name:ROTH, GERALD JAMES (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:JAMES
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 1:952 21ST AVE E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-3511
Mailing Address - Country:US
Mailing Address - Phone:206-324-1360
Mailing Address - Fax:
Practice Address - Street 1:952 21ST AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-3511
Practice Address - Country:US
Practice Address - Phone:206-764-2475
Practice Address - Fax:206-764-2689
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00010405282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital