Healthcare Provider Details

I. General information

NPI: 1467984096
Provider Name (Legal Business Name): ROTH BUN EA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2017
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 ANDERSON RD STE 19
DAVIS CA
95616-3505
US

IV. Provider business mailing address

635 ANDERSON RD STE 19
DAVIS CA
95616-3505
US

V. Phone/Fax

Practice location:
  • Phone: 530-758-1810
  • Fax: 530-758-1896
Mailing address:
  • Phone: 530-758-1810
  • Fax: 530-758-1896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5893
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: