Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 28647 | KY |
Y | 207NS0135X | Procedural Dermatology | 28647 | KY |
NPI | 1134193212 |
---|---|
Provider Name | Dr. John G Roth |
First Address | Lexington, KY 40503-2410 |
Second Address | Lexington, KY 40503-2410 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2006 |
Last Update Date | 06/01/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
64286479 | (05) | KY |
F27002 | (02) |