Provider Demographics
NPI:1104174788
Name:ROTH, BENJAMIN DUNCAN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:DUNCAN
Last Name:ROTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 MORNING VIEW DR
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-4264
Mailing Address - Country:US
Mailing Address - Phone:858-880-8704
Mailing Address - Fax:
Practice Address - Street 1:340 RANCHEROS DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2900
Practice Address - Country:US
Practice Address - Phone:760-744-3672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)