Provider Demographics
NPI:1073526471
Name:ROTH, SAMUEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:158 EAST MAIN ST
Mailing Address - Street 2:STE 7
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:631-271-4180
Mailing Address - Fax:631-271-4184
Practice Address - Street 1:158 EAST MAIN ST
Practice Address - Street 2:STE 7
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-271-4180
Practice Address - Fax:631-271-4184
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY904072086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY909331Medicare ID - Type Unspecified
B87496Medicare UPIN