Provider Demographics
NPI:1104911486
Name:ROTH, MICHAEL E (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:ROTH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 BRIGGS ST STE 600
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78224-1272
Mailing Address - Country:US
Mailing Address - Phone:210-872-3668
Mailing Address - Fax:210-428-6317
Practice Address - Street 1:1901 BABCOCK RD STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4544
Practice Address - Country:US
Practice Address - Phone:210-872-3668
Practice Address - Fax:210-428-6317
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1272213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121586504Medicaid
480034724OtherMEDICARE RAILROAD
83000GOtherBLUE CROSS BLUE SHIELD
U54805Medicare UPIN
480034724OtherMEDICARE RAILROAD
83000GOtherBLUE CROSS BLUE SHIELD