Provider Demographics
NPI:1891707105
Name:ROTH, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1746 COLE BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80401-3208
Mailing Address - Country:US
Mailing Address - Phone:303-914-8800
Mailing Address - Fax:303-716-3777
Practice Address - Street 1:1746 COLE BLVD
Practice Address - Street 2:STE 150
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80401-3208
Practice Address - Country:US
Practice Address - Phone:303-914-8800
Practice Address - Fax:303-716-3777
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO294152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01294156Medicaid
COC809549Medicare PIN
COC801369Medicare PIN
CO300064080Medicare PIN
COE57881Medicare UPIN
COC804015Medicare PIN
CO01294156Medicaid
COCH6728Medicare PIN
COC803975Medicare PIN