Provider Demographics
NPI:1972502581
Name:ROTH, RICHARD STAT (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:STAT
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 1:100 EDDIE JUNGEMANN DRIVE, SUITE B
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31408
Mailing Address - Country:US
Mailing Address - Phone:912-354-5543
Mailing Address - Fax:912-354-9365
Practice Address - Street 1:100 EDDIE JUNGEMANN DRIVE, SUITE B
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31408
Practice Address - Country:US
Practice Address - Phone:912-964-7684
Practice Address - Fax:912-354-9365
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036446207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000532441EMedicaid
GA440003516OtherRR MEDICARE
GA454524OtherBCBS
SCG36446Medicaid
GA440003516OtherRR MEDICARE
SCG36446Medicaid