Provider Demographics
NPI:1225133390
Name:ROTH, LAWRENCE WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:WILLIAM
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 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2955 S BROADWAY
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-1526
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79450207R00000X, 207RG0300X
CO47008207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO019508OtherKAISER COMMERCIAL NUMBER
CA00G794500Medicaid
CO09759221Medicaid
CA00G794500Medicaid
COCO301528Medicare PIN
CA00G794500Medicare PIN
CAG13576Medicare UPIN