Provider Demographics
NPI:1508861121
Name:ROTH, ROBERT T (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
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 1:2995 DREW ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-315-7496
Mailing Address - Fax:
Practice Address - Street 1:1840 MEASE DR
Practice Address - Street 2:SUITE 301
Practice Address - City:SAFETY HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34695-6602
Practice Address - Country:US
Practice Address - Phone:727-712-3233
Practice Address - Fax:727-712-1853
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82877208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2612166500Medicaid
FLH47876Medicare UPIN
03167YMedicare PIN