Healthcare Provider Details

I. General information

NPI: 1528210416
Provider Name (Legal Business Name): TOMER ABRAHAM ROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2008
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10666 N TOREY PINES RD 100C
LA JOLLA CA
92037
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD # 4S-205
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 858-554-2626
  • Fax:
Mailing address:
  • Phone: 858-605-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number241668-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: