Provider Demographics
NPI:1275501876
Name:ROTH, WALTER E III (DPM)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:E
Last Name:ROTH
Suffix:III
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:925 WILLISTON PARK PT
Mailing Address - Street 2:SUITE 1009
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2114
Mailing Address - Country:US
Mailing Address - Phone:407-323-2566
Mailing Address - Fax:407-324-3577
Practice Address - Street 1:925 WILLISTON PARK PT
Practice Address - Street 2:SUITE 1009
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2114
Practice Address - Country:US
Practice Address - Phone:407-323-2566
Practice Address - Fax:407-324-3577
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO0001719213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057893200Medicaid
480014891OtherRAILROAD MEDICARE
8316514011OtherCIGNA
FL65059Medicare PIN
T11672Medicare UPIN
FL65059ZMedicare PIN
480014891OtherRAILROAD MEDICARE