=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801812441
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTOINETTE R. ROTH M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10666 N TORREY PINES RD
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-1027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-554-2626
-----------------------------------------------------
Fax | 858-784-5933
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 54433 FILE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90074-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-784-5767
-----------------------------------------------------
Fax | 858-784-5933
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | A83151
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------