Provider Demographics
NPI:1326487596
Name:ROTH, KYLE MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:MARTIN
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1701 N SENATE BLVD
Mailing Address - Street 2:AG012
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1239
Mailing Address - Country:US
Mailing Address - Phone:317-962-3525
Mailing Address - Fax:
Practice Address - Street 1:1701 N. SENATE BLVD., AG012
Practice Address - Street 2:INDIANA UNIVERSITY SOM
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-962-3525
Practice Address - Fax:317-963-5394
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01075251A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine