Provider Demographics
NPI:1255490322
Name:ROTH, GERALD B (DO)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:B
Last Name:ROTH
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:5055 E BROADWAY BLVD STE A100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3629
Mailing Address - Country:US
Mailing Address - Phone:520-327-0460
Mailing Address - Fax:520-795-0225
Practice Address - Street 1:6236 E PIMA ST STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-3164
Practice Address - Country:US
Practice Address - Phone:520-327-6874
Practice Address - Fax:520-327-0028
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2021-11-08
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Provider Licenses
StateLicense IDTaxonomies
AZ2224207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD47149Medicare UPIN