Provider Demographics
NPI:1417965674
Name:DE ROTH, GEORGINE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGINE
Middle Name:
Last Name:DE 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 1:362 W MISSION AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-1738
Mailing Address - Country:US
Mailing Address - Phone:760-741-1224
Mailing Address - Fax:760-741-1010
Practice Address - Street 1:362 W MISSION AVE STE 105
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-1738
Practice Address - Country:US
Practice Address - Phone:760-741-1224
Practice Address - Fax:760-741-1010
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0052207Q00000X
CAC183787207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI48118Medicare UPIN
TX8G2749Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER