Provider Demographics
NPI:1992932776
Name:ROUTH, ROBERT H (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:H
Last Name:ROUTH
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 1:415 N CAUSEWAY
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-5235
Mailing Address - Country:US
Mailing Address - Phone:386-451-4122
Mailing Address - Fax:
Practice Address - Street 1:415 N CAUSEWAY
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-5235
Practice Address - Country:US
Practice Address - Phone:386-427-4143
Practice Address - Fax:386-427-0711
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.204049207W00000X
LA390200000X
FLME 115506207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
HC560ZOtherMEDICARE ID