Healthcare Provider Details

I. General information

NPI: 1417965674
Provider Name (Legal Business Name): GEORGINE DE ROTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

362 W MISSION AVE STE 105
ESCONDIDO CA
92025-1738
US

IV. Provider business mailing address

362 W MISSION AVE STE 105
ESCONDIDO CA
92025-1738
US

V. Phone/Fax

Practice location:
  • Phone: 760-741-1224
  • Fax: 760-741-1010
Mailing address:
  • Phone: 760-741-1224
  • Fax: 760-741-1010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM0052
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC183787
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: