Provider Demographics
NPI:1528022472
Name:ROTH, STEPHANIE DIANE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANE
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 1:1335 E WHITESTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-7598
Mailing Address - Country:US
Mailing Address - Phone:512-255-6860
Mailing Address - Fax:512-255-6860
Practice Address - Street 1:1335 E WHITESTONE BLVD
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-7598
Practice Address - Country:US
Practice Address - Phone:512-255-6860
Practice Address - Fax:512-255-6860
Is Sole Proprietor?:No
Enumeration Date:2006-04-15
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7091207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG83058Medicare UPIN
TX8C1033Medicare ID - Type Unspecified