Provider Demographics
NPI:1053350678
Name:ROTH, STUART TODD (MD)
Entity type:Individual
Prefix:DR
First Name:STUART
Middle Name:TODD
Last Name:ROTH
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 1:791 WALNUT KNOLL LN
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-8839
Mailing Address - Country:US
Mailing Address - Phone:901-755-7001
Mailing Address - Fax:901-753-2896
Practice Address - Street 1:1100 BELK BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5373
Practice Address - Country:US
Practice Address - Phone:662-232-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2023-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS127872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS116170Medicaid
MS116170Medicaid