Provider Demographics
NPI:1467984096
Name:EA, ROTH BUN
Entity Type:Individual
Prefix:
First Name:ROTH
Middle Name:BUN
Last Name:EA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 ANDERSON RD STE 19
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-3505
Mailing Address - Country:US
Mailing Address - Phone:530-758-1810
Mailing Address - Fax:530-758-1896
Practice Address - Street 1:635 ANDERSON RD STE 19
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3505
Practice Address - Country:US
Practice Address - Phone:530-758-1810
Practice Address - Fax:530-758-1896
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5893213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE5893OtherMEDICAL LICENSE
NMPOD436OtherMEDICAL LICENSE