Provider Demographics
NPI:1366780819
Name:ROTH, MATTHEW C
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:ROTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 BACON RANCH RD
Mailing Address - Street 2:APT 302
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-2921
Mailing Address - Country:US
Mailing Address - Phone:803-554-1159
Mailing Address - Fax:
Practice Address - Street 1:36000 DARNALL LOOP
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5095
Practice Address - Country:US
Practice Address - Phone:254-288-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Pathology