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1861687923

NPI Code Detail

MEDICARE: DR. DANIEL CHRISTOPHER ROTH DO, MBA, MS

MEDICARE: DR. DANIEL CHRISTOPHER ROTH DO, MBA, MS

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	208100000X	Physical Medicine & Rehabilitation Physician	125050599	IL
2	208VP0014X	Interventional Pain Medicine Physician	02003462A	IN
3	208100000X	Physical Medicine & Rehabilitation Physician	02003462A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	790872	OTHER	IN	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861687923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL CHRISTOPHER ROTH DO, MBA, MS

Provider Business Mailing Address
First Line	:	PO BOX 670
Second Line	:
City	:	HUNTERTOWN
State	:	IN
Zip	:	46748-0670
Country	:	US
Telephone Number	:	260-748-3650
Fax Number	:	260-748-3651

Provider Business Practice Location Address
First Line	:	1721 MAGNAVOX WAY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1537
Country	:	US
Telephone Number	:	260-748-3650
Fax Number	:	260-748-3651

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

Provider Enumeration Date	:	09/12/2007
Last Update Date	:	02/04/2019

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Directions to “ DR. DANIEL CHRISTOPHER ROTH DO, MBA, MS” Practice Location

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