Provider Demographics
NPI:1245289735
Name:ROTH, DAVID JULIUS (MD)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JULIUS
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1462 MONTREAL RD STE 303
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6924
Mailing Address - Country:US
Mailing Address - Phone:770-938-9761
Mailing Address - Fax:770-938-6509
Practice Address - Street 1:1462 MONTREAL RD STE 303
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6924
Practice Address - Country:US
Practice Address - Phone:770-938-9761
Practice Address - Fax:770-938-6509
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA032284207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000405457FMedicaid
GA000405457FMedicaid
GAE95532Medicare UPIN