Provider Demographics
NPI:1922050525
Name:ROTH, RAUL FERNANDO (MD)
Entity Type:Individual
Prefix:DR
First Name:RAUL
Middle Name:FERNANDO
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:FERNANDO
Other - Middle Name:
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD,
Mailing Address - Street 1:3452 E FOOTHILL BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3142
Mailing Address - Country:US
Mailing Address - Phone:626-793-2885
Mailing Address - Fax:626-793-6262
Practice Address - Street 1:625 S FAIR OAKS AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2615
Practice Address - Country:US
Practice Address - Phone:626-793-4139
Practice Address - Fax:626-793-4324
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56414207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G564140Medicaid
CAW2223OtherMEDICARE PTAN
CA00G564140Medicaid
CAW2223OtherMEDICARE PTAN
CAWG56414DMedicare PIN