Provider Demographics
NPI:1902225782
Name:ROTH, RYAN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:ROBERT
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 1:1301 PUNCHBOWL ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2499
Mailing Address - Country:US
Mailing Address - Phone:808-691-1000
Mailing Address - Fax:
Practice Address - Street 1:1301 PUNCHBOWL ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2499
Practice Address - Country:US
Practice Address - Phone:808-691-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65430-20207R00000X
HIMD-19136207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine