Provider Demographics
NPI:1861687923
Name:ROTH, DANIEL CHRISTOPHER (DO, MBA, MS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:CHRISTOPHER
Last Name:ROTH
Suffix:
Gender:M
Credentials:DO, MBA, MS
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 670
Mailing Address - Street 2:
Mailing Address - City:HUNTERTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46748-0670
Mailing Address - Country:US
Mailing Address - Phone:260-748-3650
Mailing Address - Fax:260-748-3651
Practice Address - Street 1:1721 MAGNAVOX WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1537
Practice Address - Country:US
Practice Address - Phone:260-748-3650
Practice Address - Fax:260-748-3651
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125050599208100000X
IN02003462A208VP0014X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN790872OtherBCBS
IN200938070Medicaid