Provider Demographics
NPI:1417143553
Name:ROTH, KATHERINE RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:RAE
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46401 ROMEO PLANK RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-3510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46401 ROMEO PLANK RD
Practice Address - Street 2:SUITE 4
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-3510
Practice Address - Country:US
Practice Address - Phone:586-226-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL30263207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine