Provider Demographics
NPI:1760599278
Name:ROTH, ROBERT M (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3201 PIONEERS BLVD STE 304
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502-5963
Mailing Address - Country:US
Mailing Address - Phone:402-483-2987
Mailing Address - Fax:402-483-2980
Practice Address - Street 1:3201 PIONEERS BLVD STE 304
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-5963
Practice Address - Country:US
Practice Address - Phone:402-483-2987
Practice Address - Fax:402-483-2980
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE13499207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0100192OtherUNITED HEALTHCARE
080028069OtherRAILROAD MEDICARE
NE1772OtherBCBS
1760599278OtherTRICARE WPS
NE47068394113Medicaid
0100192OtherUNITED HEALTHCARE
080028069OtherRAILROAD MEDICARE
NE47068394113Medicaid