Provider Demographics
NPI:1699709048
Name:ROTH, BRADLEY J (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:25050 AVENUE KEARNY
Mailing Address - Street 2:SUITE 208
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1257
Mailing Address - Country:US
Mailing Address - Phone:661-430-0940
Mailing Address - Fax:661-295-0862
Practice Address - Street 1:11550 INDIAN HILLS ROAD,
Practice Address - Street 2:SUITE 310
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1203
Practice Address - Country:US
Practice Address - Phone:818-898-4900
Practice Address - Fax:818-898-4990
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-07-21
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Provider Licenses
StateLicense IDTaxonomies
CAG841332086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020048518OtherMEDICARE RAILROAD
CA00G841330Medicaid
CA00G841330C29OtherCAL OPTIMA
CA00G841330OtherINDIVIDUAL BLUE SHIELD
CA020048518OtherMEDICARE RAILROAD
CA00G841330OtherINDIVIDUAL BLUE SHIELD
CA00G841330C29OtherCAL OPTIMA