Provider Demographics
NPI:1013942606
Name:ROTH, IVAR E (DPM, MPH)
Entity Type:Individual
Prefix:
First Name:IVAR
Middle Name:E
Last Name:ROTH
Suffix:
Gender:M
Credentials:DPM, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 HOSPITAL RD
Mailing Address - Street 2:SUITE # 407
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3509
Mailing Address - Country:US
Mailing Address - Phone:949-650-1147
Mailing Address - Fax:949-650-6434
Practice Address - Street 1:351 HOSPITAL RD
Practice Address - Street 2:SUITE # 407
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3509
Practice Address - Country:US
Practice Address - Phone:949-650-1147
Practice Address - Fax:949-650-6434
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2628A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
T19214Medicare UPIN