Provider Demographics
NPI:1770879413
Name:ROTH, NICOLE MEGAN (DPM)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MEGAN
Last Name:ROTH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21150
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80308-4150
Mailing Address - Country:US
Mailing Address - Phone:303-546-9158
Mailing Address - Fax:303-546-9107
Practice Address - Street 1:1400 28TH ST STE 2
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1096
Practice Address - Country:US
Practice Address - Phone:303-449-2000
Practice Address - Fax:303-449-9475
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPOD.0000829213E00000X
FLPO3661213E00000X, 213ES0103X
FLPR235213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPR235OtherPODIATRIC RESIDENT
CO9000168464Medicaid
FLPO 3661OtherPODIATRIC MEDICAL LICENSE
COPOD.0000829OtherLICENSE