Provider Demographics
NPI:1417361593
Name:ROTH, TRAVIS (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
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:PO BOX 17567
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32522-7567
Mailing Address - Country:US
Mailing Address - Phone:850-916-8423
Mailing Address - Fax:
Practice Address - Street 1:1040 GULF BREEZE PKWY STE 204
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-7808
Practice Address - Country:US
Practice Address - Phone:850-916-8693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME143139207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106561400Medicaid