Basic Information
| Provider Information | |||||||||
| NPI: | 1477637437 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 GREENWAY PLZ | ||||||||
| Address2: | SUITE 910 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770460297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137981750 | ||||||||
| FaxNumber: | 7137981144 | ||||||||
| Practice Location | |||||||||
| Address1: | 6701 FANNIN ST | ||||||||
| Address2: | 8TH FLOOR | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8328223160 | ||||||||
| FaxNumber: | 8328253159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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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 | 2088P0231X | F5729 | TX | Y | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
ID Information
| ID | Type | State | Issuer | Description | 136180004 | 05 | TX | MEDICAID |