Provider Demographics
NPI:1144210279
Name:ROTH, MARK D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:785 5TH AVENUE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:717-217-4217
Practice Address - Street 1:45 ROADSIDE AVE
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:PA
Practice Address - Zip Code:17268-2542
Practice Address - Country:US
Practice Address - Phone:717-762-7155
Practice Address - Fax:717-762-6929
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD060014L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA25-1716306OtherMULTIPLAN/PHCS
MD546216-01OtherMD BLUE SHIELD
PA367632OtherMAMSI
PA6720367OtherAETNA HMO
PA867633OtherMEDICARE GROUP #
PAP00700657OtherRAILROAD MEDICARE
PA02195701OtherCAPITAL BLUE CROSS
PA25-1716306OtherINFORMED
PA25-1716306OtherDEVON
PA25-1716306OtherHEALTHNET/TRICARE
PA990003822OtherMEDICARE RAILROAD RETIRE
PA1007307260034OtherMEDICAID GROUP #
PA25-1716306OtherGREATWEST HEALTHCARE
PA5234477OtherAETNA HMO
PA25-1716306OtherSOUTH CENTRAL PREFERRED
PA257729OtherUNISON
PA908528OtherHIGHMARK BLUESHIELD
PAG920-0109/233CCUOtherCAREFIRST
PAMD060014LOtherLICENSE
PA0016462400002Medicaid
PA1561881OtherGATEWAY
PA120420403OtherDEPT OF LABOR
PA25-1716306OtherFIRST HEALTH
MD267632OtherMAMSI OP CHOICE
PA25-1716306OtherHEALTH AMERICA
PA25-1716306OtherINTERGROUP
PA5234477OtherAETNA NON-HMO
PA810688OtherAETNA PPO
PA810688OtherAETNA PPO
PA990003822OtherMEDICARE RAILROAD RETIRE
PABR5295109OtherDEA