Provider Demographics
NPI:1609971027
Name:ROTH, ROBERT HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:HOWARD
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:PO BOX 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5637
Mailing Address - Fax:818-837-5589
Practice Address - Street 1:25775 MCBEAN PKWY
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-3708
Practice Address - Country:US
Practice Address - Phone:661-424-8830
Practice Address - Fax:661-424-8831
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2023-09-05
Deactivation Date:2023-08-02
Deactivation Code:
Reactivation Date:2023-09-05
Provider Licenses
StateLicense IDTaxonomies
CAG32092207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G320920Medicaid
CAA45000Medicare UPIN
CA00G320920Medicaid