Basic Information
| Provider Information | |||||||||
| NPI: | 1124027362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 446 TAMIAMI TRL S | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342852625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414833319 | ||||||||
| FaxNumber: | 9414833406 | ||||||||
| Practice Location | |||||||||
| Address1: | 446 TAMIAMI TRL S | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342852625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414833319 | ||||||||
| FaxNumber: | 9414833406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 07/02/2010 | ||||||||
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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 | 207ZC0500X | ME53084 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | ME53084 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0105X | ME53084 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 250574600 | 05 | FL | MEDICAID |