Provider Demographics
NPI:1386683886
Name:ROTH, RUDOLF (MD)
Entity Type:Individual
Prefix:
First Name:RUDOLF
Middle Name:
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 1:250 KING OF PRUSSIA RD
Mailing Address - Street 2:
Mailing Address - City:RADNOR
Mailing Address - State:PA
Mailing Address - Zip Code:19087
Mailing Address - Country:US
Mailing Address - Phone:610-902-2400
Mailing Address - Fax:
Practice Address - Street 1:250 KING OF PRUSSIA RD
Practice Address - Street 2:
Practice Address - City:RADNOR
Practice Address - State:PA
Practice Address - Zip Code:19087
Practice Address - Country:US
Practice Address - Phone:610-902-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD073956L207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018542420003Medicaid
PA0018542420003Medicaid
H46482Medicare UPIN