=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497758098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD LEE ROTH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2005
-----------------------------------------------------
Last Update Date | 10/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6845 ELM ST STE 210
-----------------------------------------------------
City | MC LEAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22101-3822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-821-2337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6845 ELM ST STE 210
-----------------------------------------------------
City | MC LEAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22101-3822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-821-2337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 0101028447
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------