Basic Information
| Provider Information | |||||||||
| NPI: | 1841851474 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN DIEGO SPECIALISTS KENNETH J ROTH GEN PTR | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAN DIEGO SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8765 AERO DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585410181 | ||||||||
| FaxNumber: | 8587153809 | ||||||||
| Practice Location | |||||||||
| Address1: | 8765 AERO DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585410181 | ||||||||
| FaxNumber: | 8587153809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2019 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROTH | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8585410181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.