Healthcare Provider Details

I. General information

NPI: 1629219316
Provider Name (Legal Business Name): BRADLEY I. ROTH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2009
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 S ANDREWS AVE FL 2
FORT LAUDERDALE FL
33316-2509
US

IV. Provider business mailing address

1700 NW 49TH ST STE 125
FORT LAUDERDALE FL
33309-3750
US

V. Phone/Fax

Practice location:
  • Phone: 954-355-3490
  • Fax: 954-355-3498
Mailing address:
  • Phone: 954-355-3490
  • Fax: 954-355-3498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOS 10192
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number47451
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberOS10192
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: