Healthcare Provider Details

I. General information

NPI: 1376246538
Provider Name (Legal Business Name): ANDREW MICHAEL ROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7165 N PIMA CANYON DR
TUCSON AZ
85718-1407
US

IV. Provider business mailing address

7165 N PIMA CANYON DR
TUCSON AZ
85718-1407
US

V. Phone/Fax

Practice location:
  • Phone: 312-766-4949
  • Fax: 312-766-4925
Mailing address:
  • Phone: 520-694-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberR80690
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: