Provider Demographics
NPI:1477593085
Name:ROTH, DAVID L (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 HERITAGE WAY
Mailing Address - Street 2:#2100
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3158
Mailing Address - Country:US
Mailing Address - Phone:406-257-8992
Mailing Address - Fax:406-257-8996
Practice Address - Street 1:350 HERITAGE WAY
Practice Address - Street 2:#2100
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3158
Practice Address - Country:US
Practice Address - Phone:406-257-8992
Practice Address - Fax:406-257-8996
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT7895207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT36218Medicaid
MT593OtherBLUE CROSS
MTM011000969OtherMEDICARE PTAN
MTM011000969OtherMEDICARE PTAN