Healthcare Provider Details

I. General information

NPI: 1881889913
Provider Name (Legal Business Name): DANIEL E ROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 EASTERN AVE
BALTIMORE MD
21224-2735
US

IV. Provider business mailing address

615 N WOLFE ST BOX #1007
BALTIMORE MD
21205-2103
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-0963
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0066546
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: