Provider Demographics
NPI:1053770065
Name:ROTH, KEITH RICHARD (DPT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:RICHARD
Last Name:ROTH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 MULLIGAN DR
Mailing Address - Street 2:
Mailing Address - City:NEW VIENNA
Mailing Address - State:OH
Mailing Address - Zip Code:45159-9053
Mailing Address - Country:US
Mailing Address - Phone:440-453-3657
Mailing Address - Fax:
Practice Address - Street 1:1108 NORTHVIEW DR
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-1184
Practice Address - Country:US
Practice Address - Phone:937-393-6163
Practice Address - Fax:937-393-6295
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14950225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist