Provider Demographics
NPI:1841851474
Name:SAN DIEGO SPECIALISTS KENNETH J ROTH GEN PTR
Entity type:Organization
Organization Name:SAN DIEGO SPECIALISTS KENNETH J ROTH GEN PTR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-541-0181
Mailing Address - Street 1:8765 AERO DR STE 130
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1767
Mailing Address - Country:US
Mailing Address - Phone:858-541-0181
Mailing Address - Fax:858-715-3809
Practice Address - Street 1:8765 AERO DR STE 130
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1767
Practice Address - Country:US
Practice Address - Phone:858-541-0181
Practice Address - Fax:858-715-3809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-25
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty