Provider Demographics
NPI:1487791026
Name:ROTH, ROB ROY (MD)
Entity type:Individual
Prefix:DR
First Name:ROB
Middle Name:ROY
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4234
Mailing Address - Country:US
Mailing Address - Phone:253-403-1043
Mailing Address - Fax:253-403-1357
Practice Address - Street 1:315 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4234
Practice Address - Country:US
Practice Address - Phone:253-403-1043
Practice Address - Fax:253-403-1357
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018956207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA76104OtherLABOR & INDUSTRIES
WA8645202Medicaid
WA220007619Medicare PIN
WA76104OtherLABOR & INDUSTRIES
WA001050402Medicare ID - Type Unspecified
WA8645202Medicaid