Provider Demographics
NPI:1730128083
Name:ROTH, JOHN B (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
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 950293
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0293
Mailing Address - Country:US
Mailing Address - Phone:888-987-1875
Mailing Address - Fax:405-609-1491
Practice Address - Street 1:3333 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-4613
Practice Address - Country:US
Practice Address - Phone:502-452-6337
Practice Address - Fax:502-458-5327
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY16654208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64166549Medicaid