Provider Demographics
NPI:1568452761
Name:ROTH, HERBERT J SR (MD)
Entity Type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:J
Last Name:ROTH
Suffix:SR
Gender:M
Credentials:MD
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Mailing Address - Street 1:31815 SOUTHFIELD RD STE 10
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5471
Mailing Address - Country:US
Mailing Address - Phone:248-644-2700
Mailing Address - Fax:248-644-4783
Practice Address - Street 1:31815 SOUTHFIELD RD
Practice Address - Street 2:STE 14
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025-5471
Practice Address - Country:US
Practice Address - Phone:248-644-2700
Practice Address - Fax:248-644-4783
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2020-03-10
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Provider Licenses
StateLicense IDTaxonomies
MI4301024915208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D91253Medicare UPIN