Provider Demographics
NPI:1083695233
Name:ROTH, KATHERINE G (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:G
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12 MEDICAL DR
Mailing Address - Street 2:STE D
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1588
Mailing Address - Country:US
Mailing Address - Phone:631-928-1222
Mailing Address - Fax:631-928-8605
Practice Address - Street 1:12 MEDICAL DR
Practice Address - Street 2:STE D
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1588
Practice Address - Country:US
Practice Address - Phone:631-928-1222
Practice Address - Fax:631-928-8605
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2073192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01762101Medicaid
NY96X631Medicare PIN
NYKR096X6310Medicare ID - Type Unspecified
NYF29054Medicare UPIN