Provider Demographics
NPI:1225123458
Name:ROTH, DELFORD MARK (DO)
Entity Type:Individual
Prefix:
First Name:DELFORD
Middle Name:MARK
Last Name:ROTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:416 VALLEY VIEW DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-1486
Mailing Address - Country:US
Mailing Address - Phone:308-633-9021
Mailing Address - Fax:308-633-9023
Practice Address - Street 1:416 VALLEY VIEW DR
Practice Address - Street 2:SUITE 301
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-1486
Practice Address - Country:US
Practice Address - Phone:308-633-9021
Practice Address - Fax:308-633-9023
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-12-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NE491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE491OtherSTATE LICENSE NUMBER