Healthcare Provider Details

I. General information

NPI: 1215095948
Provider Name (Legal Business Name): VICTOR S ROTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 W ALEXIS RD GM POWERTRAIN MEDICAL DEPARTMENT
TOLEDO OH
43612-4044
US

IV. Provider business mailing address

5664 VILLA FRANCE AVE
ANN ARBOR MI
48103-9086
US

V. Phone/Fax

Practice location:
  • Phone: 734-470-4244
  • Fax:
Mailing address:
  • Phone: 734-669-0673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number35.056920
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number4301057261
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: