Provider Demographics
NPI:1982645040
Name:ROTH, STEPHEN L (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 N COMMERCE PKWY
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3957
Mailing Address - Country:US
Mailing Address - Phone:954-967-6550
Mailing Address - Fax:954-893-6818
Practice Address - Street 1:3702 WASHINGTON ST
Practice Address - Street 2:SUITE 303
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8282
Practice Address - Country:US
Practice Address - Phone:954-967-6550
Practice Address - Fax:954-967-6553
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 37888207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065751400Medicaid
FL93882UMedicare ID - Type Unspecified
FLD63041Medicare UPIN