Healthcare Provider Details

I. General information

NPI: 1144213604
Provider Name (Legal Business Name): TIMOTHY J ROTH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date: 03/23/2006
Reactivation Date: 04/11/2006

III. Provider practice location address

255 W BULLARD AVE
CLOVIS CA
93612-0861
US

IV. Provider business mailing address

255 W BULLARD AVE #102
CLOVIS CA
93612-0861
US

V. Phone/Fax

Practice location:
  • Phone: 559-299-2128
  • Fax: 559-299-3494
Mailing address:
  • Phone: 559-299-2128
  • Fax: 559-299-3494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A5200
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: