Provider Demographics
NPI:1710970561
Name:ROTH, TRACEY (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:
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 1:399 9TH ST N
Mailing Address - Street 2:#300
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5820
Mailing Address - Country:US
Mailing Address - Phone:239-624-4200
Mailing Address - Fax:239-624-4201
Practice Address - Street 1:399 9TH ST N
Practice Address - Street 2:#300
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5820
Practice Address - Country:US
Practice Address - Phone:239-624-4200
Practice Address - Fax:239-624-4201
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58465207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14867AOtherBCBS
14867WOtherMEDICARE
FL056497400Medicaid
FL14867AOtherBCBS
FL14867XMedicare ID - Type Unspecified
14867WOtherMEDICARE
FL056497400Medicaid