Provider Demographics
NPI:1215164348
Name:ROTH, NATHAN THOMAS (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:THOMAS
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 161180
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32716-1180
Mailing Address - Country:US
Mailing Address - Phone:904-388-6949
Mailing Address - Fax:904-388-1841
Practice Address - Street 1:1800 BARRS ST
Practice Address - Street 2:RADIOLOGY DEPT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4704
Practice Address - Country:US
Practice Address - Phone:904-308-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME1233222085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology