Provider Demographics
NPI:1932278793
Name:ROTH, JOHN DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:ROTH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7064 BERACASA WAY
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433
Mailing Address - Country:US
Mailing Address - Phone:561-392-1777
Mailing Address - Fax:561-750-2361
Practice Address - Street 1:7064 BERACASA WAY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433
Practice Address - Country:US
Practice Address - Phone:561-392-1777
Practice Address - Fax:561-750-2361
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3916111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
35005495OtherRR MEDICARE
FL388489500Medicaid
FL388489500Medicaid
T55973Medicare UPIN