Basic Information
| Provider Information | |||||||||
| NPI: | 1063622090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | STUART | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9050 TRADD ST | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334345902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048289783 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9050 TRADD ST | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334345902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048289783 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 08/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 0116018547 | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 0101245157 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | ME 112786 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0202X | ME112786 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | C09463 | 01 | VA | GROUP PTAN | OTHER |