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1124098579

NPI Code Detail

MEDICARE: EARL EUGENE ROTH JR. MD

MEDICARE: EARL EUGENE ROTH JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	14021	AZ
2	208D00000X	General Practice Physician	14021	AZ
3	207P00000X	Emergency Medicine Physician	14021	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124098579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EARL EUGENE ROTH JR. MD

Provider Business Mailing Address
First Line	:	11001 N BLACK CANYON HWY
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-4757
Country	:	US
Telephone Number	:	602-371-2515
Fax Number	:

Provider Business Practice Location Address
First Line	:	5891 W EUGIE AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85304-1252
Country	:	US
Telephone Number	:	602-588-6703
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	10/11/2007

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Directions to “ EARL EUGENE ROTH JR. MD” Practice Location

Language	Start Address	Practice Location

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