Healthcare Provider Details

I. General information

NPI: 1457566101
Provider Name (Legal Business Name): MATT D ROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 09/29/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 N REYNOLDS RD STE 260
TOLEDO OH
43615-2070
US

IV. Provider business mailing address

660 BEAVER CREEK CIR SUITE 110
MAUMEE OH
43537-1745
US

V. Phone/Fax

Practice location:
  • Phone: 419-578-4280
  • Fax: 419-537-5684
Mailing address:
  • Phone: 419-891-6210
  • Fax: 419-893-3232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35088737
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35-088737
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: