Provider Demographics
NPI:1386684231
Name:ROTH, ROBERT B (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:B
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:ATTN: CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-271-1633
Mailing Address - Fax:414-271-5071
Practice Address - Street 1:2350 N LAKE DR
Practice Address - Street 2:SUITE 400
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-271-1633
Practice Address - Fax:414-271-5071
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2012-06-12
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Provider Licenses
StateLicense IDTaxonomies
WI29385207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31421500Medicaid
WI02665Medicare ID - Type Unspecified
WIC65195Medicare UPIN