Provider Demographics
NPI:1144213604
Name:ROTH, TIMOTHY J (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:ROTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W BULLARD AVE
Mailing Address - Street 2:#102
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0861
Mailing Address - Country:US
Mailing Address - Phone:559-299-2128
Mailing Address - Fax:559-299-3494
Practice Address - Street 1:255 W BULLARD AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0861
Practice Address - Country:US
Practice Address - Phone:559-299-2128
Practice Address - Fax:559-299-3494
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2010-07-29
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
CA20A5200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A52000Medicare PIN
CAE25311Medicare UPIN