Provider Demographics
NPI:1497415731
Name:ROTH, SAMUEL BENJAMIN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:BENJAMIN
Last Name:ROTH
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 W SAM HOUSTON PKWY S APT 5404
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-2151
Mailing Address - Country:US
Mailing Address - Phone:402-469-1006
Mailing Address - Fax:
Practice Address - Street 1:17520 W GRAND PKWY S STE 100
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-4759
Practice Address - Country:US
Practice Address - Phone:281-725-5895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13570642251X0800X, 2251S0007X
TXAT85492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT8549OtherAT LICENSE