Basic Information
| Provider Information | |||||||||
| NPI: | 1699709048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25050 AVENUE KEARNY | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | VALENCIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913551257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6614300940 | ||||||||
| FaxNumber: | 6612950862 | ||||||||
| Practice Location | |||||||||
| Address1: | 11550 INDIAN HILLS ROAD, | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913451203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188984900 | ||||||||
| FaxNumber: | 8188984990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/21/2015 | ||||||||
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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 | 2086S0127X | G84133 | CA | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 020048518 | 01 | CA | MEDICARE RAILROAD | OTHER | 00G841330 | 05 | CA | MEDICAID | 00G841330C29 | 01 | CA | CAL OPTIMA | OTHER | 00G841330 | 01 | CA | INDIVIDUAL BLUE SHIELD | OTHER |