Provider Demographics
NPI:1902868201
Name:ROTH, JEFFREY CLARK (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:CLARK
Last Name:ROTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:10470 ROSE ANN CIR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-4359
Mailing Address - Country:US
Mailing Address - Phone:714-220-9135
Mailing Address - Fax:714-995-4455
Practice Address - Street 1:2600 REDONDO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2329
Practice Address - Country:US
Practice Address - Phone:562-988-7000
Practice Address - Fax:562-988-7430
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5342207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine