Provider Demographics
NPI:1649273889
Name:ROTH, BRIAN P (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:P
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 1:1022 W IVY AVE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-4107
Mailing Address - Country:US
Mailing Address - Phone:509-765-7845
Mailing Address - Fax:509-765-5192
Practice Address - Street 1:1022 W IVY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-4107
Practice Address - Country:US
Practice Address - Phone:509-765-7845
Practice Address - Fax:509-765-5192
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029599207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7729007Medicaid
WA000304586Medicare ID - Type Unspecified
WA7729007Medicaid