Provider Demographics
NPI:1497758098
Name:ROTH, RICHARD LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEE
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 1:6845 ELM ST
Mailing Address - Street 2:STE 210
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3822
Mailing Address - Country:US
Mailing Address - Phone:703-821-2337
Mailing Address - Fax:
Practice Address - Street 1:6845 ELM ST
Practice Address - Street 2:STE 210
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3822
Practice Address - Country:US
Practice Address - Phone:703-821-2337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010284472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8555OtherCAREFILRST BC BS
VA059999OtherANTHEM BC BS
VA215112OtherMAMSI
VA215112OtherALLIANCE
VAD09501Medicare UPIN
VA177497Medicare ID - Type Unspecified