Provider Demographics
NPI:1952603334
Name:POTH, ROY KEITH (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:KEITH
Last Name:POTH
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 1:15400 FOX RUN DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78737-8611
Mailing Address - Country:US
Mailing Address - Phone:512-626-2643
Mailing Address - Fax:512-301-3836
Practice Address - Street 1:15400 FOX RUN DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78737-8611
Practice Address - Country:US
Practice Address - Phone:512-626-2643
Practice Address - Fax:512-301-3836
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD 51572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD 5157OtherTEXAS STATE BOARD OF MEDICAL EXAMINERS