Provider Demographics
NPI:1740387976
Name:RICHARD L ROTH MD PC
Entity Type:Organization
Organization Name:RICHARD L ROTH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-821-2337
Mailing Address - Street 1:6845 ELM STREET
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3822
Mailing Address - Country:US
Mailing Address - Phone:703-821-2337
Mailing Address - Fax:
Practice Address - Street 1:6845 ELM STREET
Practice Address - Street 2:SUITE 210
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3822
Practice Address - Country:US
Practice Address - Phone:703-821-2337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010284472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA059999OtherANTHEM BCBS
VA010255155Medicaid
DC8555OtherCARE FIRST BCBS
DC8555OtherCARE FIRST BCBS
VA177497Medicare PIN