Provider Demographics
NPI:1811135817
Name:ROTH, BRYAN JAMES (DPM)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JAMES
Last Name:ROTH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5423 W BEVERLY RD
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2896
Mailing Address - Country:US
Mailing Address - Phone:602-344-5056
Mailing Address - Fax:602-344-5048
Practice Address - Street 1:2601 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4973
Practice Address - Country:US
Practice Address - Phone:602-344-5056
Practice Address - Fax:602-344-5048
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0686213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery