Provider Demographics
NPI:1124098579
Name:ROTH, EARL EUGENE JR (MD)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:EUGENE
Last Name:ROTH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11001 N BLACK CANYON HWY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4757
Mailing Address - Country:US
Mailing Address - Phone:602-371-2515
Mailing Address - Fax:
Practice Address - Street 1:5891 W EUGIE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1252
Practice Address - Country:US
Practice Address - Phone:602-588-6703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14021208000000X, 208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ448424Medicaid
AZ60791Medicare ID - Type Unspecified
AZWCKJMMedicare ID - Type Unspecified
AZ67137Medicare ID - Type Unspecified
AZ67138Medicare ID - Type Unspecified
AZ21575Medicare ID - Type Unspecified
AZ448424Medicaid
AZG66601Medicare UPIN
AZWCKHQMedicare ID - Type Unspecified