Provider Demographics
NPI:1225250087
Name:G&J ROTH PROF CORP.
Entity Type:Organization
Organization Name:G&J ROTH PROF CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:559-299-2128
Mailing Address - Street 1:255 W BULLARD AVE STE 102
Mailing Address - Street 2:
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 STE 102
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY49258YMedicare PIN
CA6181490002Medicare NSC