Provider Demographics
NPI:1437684057
Name:ROTH, TAYLOR (MD)
Entity Type:Individual
Prefix:
First Name:TAYLOR
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:KEESLER AFB
Mailing Address - Street 2:301 FISHER STREET
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39534
Mailing Address - Country:US
Mailing Address - Phone:228-376-2273
Mailing Address - Fax:
Practice Address - Street 1:KEESLER AFB
Practice Address - Street 2:301 FISHER STREET
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39534
Practice Address - Country:US
Practice Address - Phone:228-376-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-21
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS27856207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1437684057Medicaid