Healthcare Provider Details

I. General information

NPI: 1063622090
Provider Name (Legal Business Name): TODD STUART ROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9050 TRADD ST
BOCA RATON FL
33434-5902
US

IV. Provider business mailing address

9050 TRADD ST
BOCA RATON FL
33434-5902
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-9783
  • Fax:
Mailing address:
  • Phone: 804-828-9783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116018547
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101245157
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 112786
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberME112786
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: