Provider Demographics
NPI:1417453903
Name:ROTH, ADRIENNE
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 LOCKE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78208-2127
Mailing Address - Country:US
Mailing Address - Phone:201-644-8700
Mailing Address - Fax:
Practice Address - Street 1:919 LOCKE ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78208-2127
Practice Address - Country:US
Practice Address - Phone:201-644-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1417453903207Q00000X
TX122016207Q00000X
TXT3690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine