Provider Demographics
NPI:1508890971
Name:ROTH, KARLA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:KARLA
Middle Name:JEAN
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 MONROE RD
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-8399
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:3860 MONROE RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-8399
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:920-431-1967
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32183200Medicaid
F84831Medicare UPIN
07125-0156Medicare ID - Type Unspecified