Healthcare Provider Details

I. General information

NPI: 1124098579
Provider Name (Legal Business Name): EARL EUGENE ROTH JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5891 W EUGIE AVE
GLENDALE AZ
85304-1252
US

IV. Provider business mailing address

11001 N BLACK CANYON HWY
PHOENIX AZ
85029-4757
US

V. Phone/Fax

Practice location:
  • Phone: 602-588-6703
  • Fax:
Mailing address:
  • Phone: 602-371-2515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number14021
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number14021
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number14021
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: