Provider Demographics
NPI:1790751840
Name:ROTH, PATRICIA A (DO)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:A
Last Name:ROTH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:PATRICIA
Other - Middle Name:A
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:2515 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLMAR
Mailing Address - State:PA
Mailing Address - Zip Code:18915-9773
Mailing Address - Country:US
Mailing Address - Phone:215-997-2340
Mailing Address - Fax:215-997-3669
Practice Address - Street 1:2515 N BROAD ST
Practice Address - Street 2:
Practice Address - City:COLMAR
Practice Address - State:PA
Practice Address - Zip Code:18915-9773
Practice Address - Country:US
Practice Address - Phone:215-997-2340
Practice Address - Fax:215-997-3669
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05010020L207Q00000X
NJMB71449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H21595Medicare UPIN
PA103739Medicare PIN