Provider Demographics
NPI:1457566101
Name:ROTH, MATT D (MD)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:D
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 1:660 BEAVER CREEK CIR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1745
Mailing Address - Country:US
Mailing Address - Phone:419-891-6210
Mailing Address - Fax:419-893-3232
Practice Address - Street 1:2865 N REYNOLDS RD STE 260
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-2070
Practice Address - Country:US
Practice Address - Phone:419-578-4280
Practice Address - Fax:419-537-5684
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-088737207QS0010X
OH35088737207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2769839Medicaid
05455OtherPARAMOUNT
9202151OtherAETNA
000000571949OtherANTHEM
PENDINGOtherRRMC
PENDINGOtherTRICARE
PENDINGOtherRRMC
PENDINGOtherRRMC