Provider Demographics
NPI:1669433017
Name:ROETHEL, WILLIAM M (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:M
Last Name:ROETHEL
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 1:601 MARTIN LUTHER KING AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3619
Mailing Address - Country:US
Mailing Address - Phone:505-727-8000
Mailing Address - Fax:
Practice Address - Street 1:601 MARTIN LUTHER KING AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3619
Practice Address - Country:US
Practice Address - Phone:505-727-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0621207P00000X
MI4301054529207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI103311354Medicaid
MIWR054529OtherBC/BS OF MI
MIF23750Medicare UPIN
MIH26348150Medicare ID - Type Unspecified