Provider Demographics
NPI:1215095948
Name:ROTH, VICTOR S (MD)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:S
Last Name:ROTH
Suffix:
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 1:5664 VILLA FRANCE AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9086
Mailing Address - Country:US
Mailing Address - Phone:734-669-0673
Mailing Address - Fax:
Practice Address - Street 1:1455 W ALEXIS RD
Practice Address - Street 2:GM POWERTRAIN MEDICAL DEPARTMENT
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612-4044
Practice Address - Country:US
Practice Address - Phone:734-470-4244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0569202083X0100X
MI43010572612083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA17584Medicare UPIN