Provider Demographics
NPI:1942235338
Name:ROTH, DAVID M (PH D)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:ROTH
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6535 N CHARLES ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-5826
Mailing Address - Country:US
Mailing Address - Phone:410-938-5252
Mailing Address - Fax:410-938-5250
Practice Address - Street 1:6535 N CHARLES ST
Practice Address - Street 2:SUITE 300
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-5826
Practice Address - Country:US
Practice Address - Phone:410-938-5252
Practice Address - Fax:410-938-5250
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01469103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD856QOtherMEDICARE ID
MD185910500Medicaid
MD185910500Medicaid
R12669Medicare UPIN