Provider Demographics
NPI:1215934187
Name:ROTH, WILLIAM BRADLEY (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:BRADLEY
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 1:1000 W PINHOOK RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2460
Mailing Address - Country:US
Mailing Address - Phone:337-289-9155
Mailing Address - Fax:337-289-9585
Practice Address - Street 1:1000 W PINHOOK RD
Practice Address - Street 2:SUITE 304
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2460
Practice Address - Country:US
Practice Address - Phone:337-289-9155
Practice Address - Fax:337-289-9585
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14924R208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1156191Medicaid
LAP000343674Medicare PIN
LA4F205CP99Medicare PIN
LA1156191Medicaid