Provider Demographics
NPI:1790787521
Name:ROTH, ANDREW A (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:A
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 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1303 N MAIN ST STE 3C
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721-9746
Practice Address - Country:US
Practice Address - Phone:435-868-5500
Practice Address - Fax:435-868-5504
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-079283174400000X
KYC1158207V00000X
UT13111717-1205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL931181Medicare ID - Type Unspecified
ILE57889Medicare UPIN