Healthcare Provider Details

I. General information

NPI: 1932109212
Provider Name (Legal Business Name): JEFFREY JOSEPH ROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6140 S FORT APACHE RD STE 100
LAS VEGAS NV
89148-6737
US

IV. Provider business mailing address

6140 S FORT APACHE RD STE 100
LAS VEGAS NV
89148-6737
US

V. Phone/Fax

Practice location:
  • Phone: 702-450-0777
  • Fax: 702-459-7701
Mailing address:
  • Phone: 702-450-0777
  • Fax: 702-459-7701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number7663
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: