Provider Demographics
NPI:1629137278
Name:ROAT, DAVID BURTON (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BURTON
Last Name:ROAT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:BURTON
Other - Last Name:ROAT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:D O
Mailing Address - Street 1:4641 ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-2398
Mailing Address - Country:US
Mailing Address - Phone:215-831-4600
Mailing Address - Fax:215-831-4700
Practice Address - Street 1:4641 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2343
Practice Address - Country:US
Practice Address - Phone:215-831-4600
Practice Address - Fax:215-831-4700
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008990L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017602440001Medicaid
NHD08036000OtherCONTROLLED DRUG SUBSTANCE
NHD08036000OtherCONTROLLED DRUG SUBSTANCE