Provider Demographics
NPI:1912093923
Name:ROTH, JON J
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:J
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:PO BOX 231189
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92023-1189
Mailing Address - Country:US
Mailing Address - Phone:760-230-2251
Mailing Address - Fax:760-230-2253
Practice Address - Street 1:354 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5142
Practice Address - Country:US
Practice Address - Phone:760-230-2251
Practice Address - Fax:760-230-2253
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50622207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
030471215OtherTRICARE
000713416OtherAETNA
CAG08592Medicare UPIN
CAC50622Medicare ID - Type Unspecified