Healthcare Provider Details

I. General information

NPI: 1215934187
Provider Name (Legal Business Name): WILLIAM BRADLEY ROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 02/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W PINHOOK RD SUITE 304
LAFAYETTE LA
70503-2460
US

IV. Provider business mailing address

1000 W PINHOOK RD SUITE 304
LAFAYETTE LA
70503-2460
US

V. Phone/Fax

Practice location:
  • Phone: 337-289-9155
  • Fax: 337-289-9585
Mailing address:
  • Phone: 337-289-9155
  • Fax: 337-289-9585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number14924R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: