MEDICARE: DR. TRACEY ROTH M.D.

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	207RC0000X	Cardiovascular Disease Physician	17157	SD
2	207RI0011X	Interventional Cardiology Physician	ME58465	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	14867W	OTHER		MEDICARE

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
2	14867A	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1710970561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACEY ROTH M.D.

Provider Business Mailing Address
First Line	:	399 9TH ST N
Second Line	:	#300
City	:	NAPLES
State	:	FL
Zip	:	34102-5820
Country	:	US
Telephone Number	:	239-624-4200
Fax Number	:	239-624-4201

Provider Business Practice Location Address
First Line	:	399 9TH ST N
Second Line	:	#300
City	:	NAPLES
State	:	FL
Zip	:	34102-5820
Country	:	US
Telephone Number	:	239-624-4200
Fax Number	:	239-624-4201

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

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	05/02/2025

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Directions to “ DR. TRACEY ROTH M.D.” Practice Location

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