Provider Demographics
NPI:1528032950
Name:ROTH, KATHERINE A (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
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 1:820 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2466
Mailing Address - Country:US
Mailing Address - Phone:231-935-0848
Mailing Address - Fax:
Practice Address - Street 1:820 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2466
Practice Address - Country:US
Practice Address - Phone:231-935-0848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKR046406207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0PO7710Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER