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General NPI Number Information
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NPI Number | 1457566101
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Entity Type | Individual
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Provider Name | MATT D ROTH MD
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Gender | Male
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 11/03/2023
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Provider Practice Location Address
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Address Line | 2865 N REYNOLDS RD STE 260
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City | TOLEDO
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State | OH
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Zip | 43615-2070
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Country | US
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Telephone | 419-578-4280
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Fax | 419-537-5684
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Provider Business Mailing Address
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Address Line | 660 BEAVER CREEK CIR SUITE 110
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City | MAUMEE
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State | OH
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Zip | 43537-1745
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Country | US
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Telephone | 419-891-6210
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Fax | 419-893-3232
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | 35-088737
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 35088737
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License Number State | OH
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