Provider Demographics
NPI:1063673713
Name:ROTH, JULIE L (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:L
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2 DUDLEY ST
Mailing Address - Street 2:SUITE 555
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-3236
Mailing Address - Country:US
Mailing Address - Phone:401-444-4364
Mailing Address - Fax:401-444-3236
Practice Address - Street 1:2 DUDLEY ST
Practice Address - Street 2:SUITE 555
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3236
Practice Address - Country:US
Practice Address - Phone:401-444-3032
Practice Address - Fax:401-444-3205
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RILP013972084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1063673713Medicaid
RI1063673713Medicaid