Provider Demographics
NPI:1043203243
Name:ROTH, JEFFREY STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:STEPHEN
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 1:580 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7313
Mailing Address - Country:US
Mailing Address - Phone:212-752-3692
Mailing Address - Fax:212-838-5636
Practice Address - Street 1:580 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-7313
Practice Address - Country:US
Practice Address - Phone:212-752-3692
Practice Address - Fax:212-838-5636
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1828581207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F24002Medicare UPIN
NYA400053831Medicare PIN