Provider Demographics
NPI:1629219316
Name:ROTH, BRADLEY I (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:I
Last Name:ROTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-355-3490
Mailing Address - Fax:954-355-3498
Practice Address - Street 1:1601 S ANDREWS AVE FL 2
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2509
Practice Address - Country:US
Practice Address - Phone:954-355-3490
Practice Address - Fax:954-355-3498
Is Sole Proprietor?:No
Enumeration Date:2009-03-10
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 10192207X00000X
CO47451207X00000X
FLOS10192207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery