Provider Demographics
NPI:1962791947
Name:ROTH, JILL RACHEL (MD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:RACHEL
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BAYLOR PLZ
Mailing Address - Street 2:BCM 320
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3411
Mailing Address - Country:US
Mailing Address - Phone:832-428-8536
Mailing Address - Fax:
Practice Address - Street 1:1 BAYLOR PLZ
Practice Address - Street 2:BCM 320
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3411
Practice Address - Country:US
Practice Address - Phone:832-428-8536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10037382208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP10037382OtherTEXAS MEDICAL BOARD PERMIT NUMBER