Provider Demographics
NPI:1801455076
Name:ROTH, MATTHEW D
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:ROTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 N HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-2045
Mailing Address - Country:US
Mailing Address - Phone:509-458-7686
Mailing Address - Fax:509-808-2164
Practice Address - Street 1:730 N HAMILTON ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-2045
Practice Address - Country:US
Practice Address - Phone:509-458-7686
Practice Address - Fax:509-808-2164
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60963961225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPT60963961OtherWA PHYSICAL THERAPY LICENSE