Healthcare Provider Details

I. General information

NPI: 1801812441
Provider Name (Legal Business Name): ANTOINETTE R. ROTH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10666 N TORREY PINES RD
LA JOLLA CA
92037-1027
US

IV. Provider business mailing address

54433 FILE
LOS ANGELES CA
90074-0001
US

V. Phone/Fax

Practice location:
  • Phone: 858-554-2626
  • Fax: 858-784-5933
Mailing address:
  • Phone: 858-784-5767
  • Fax: 858-784-5933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA83151
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: