Provider Demographics
NPI:1831197250
Name:ROTH, DAVID ERICH (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ERICH
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 1:8222 SPRING GLADE PL
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-7653
Mailing Address - Country:US
Mailing Address - Phone:808-741-3031
Mailing Address - Fax:
Practice Address - Street 1:361 3RD ST STE A
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3580
Practice Address - Country:US
Practice Address - Phone:844-867-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC539462084P0800X, 2084P0804X, 2084P0800X
HIMD112622080P0006X
HIMD-112622084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI525-008-01Medicaid
HI525-008-01Medicaid