Provider Demographics
NPI:1316900665
Name:ROTH, JASON ERIC (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:ERIC
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:PO BOX 3649
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3649
Mailing Address - Country:US
Mailing Address - Phone:509-838-2531
Mailing Address - Fax:509-755-6580
Practice Address - Street 1:910 W 5TH AVE
Practice Address - Street 2:SUITE 1000
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2966
Practice Address - Country:US
Practice Address - Phone:509-838-2531
Practice Address - Fax:509-755-6580
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN034584207RC0000X
WAMD60015400207RC0000X
IDM10532207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808313700Medicaid
WA8538670Medicaid
ID1196022Medicare PIN
ID808313700Medicaid
WA8538670Medicaid